Transitional Care RN

Job Summary and Responsibilities

As our Transitional Care Nurse (TCN), you will serve as a pivotal leader in the Nebraska Rural Health Transformation Program (RHTP), a specialized, grant-funded initiative dedicated to advancing healthcare delivery in rural communities. You will spearhead our Remote Patient Monitoring (RPM) program, collaborating with clinical vendors to deploy innovative medical technology and provide essential physician oversight for clinical escalation. By streamlining care coordination and strengthening chronic disease management, you will play a critical role in reducing avoidable emergency department visits and readmissions for patients managing conditions like diabetes, COPD, and cardiovascular disease.

Every day you will manage the operational and administrative lifecycle of this grant-funded program, utilizing Epic analytics and predictive metrics to identify high-risk patients. Your daily workflow includes reviewing discharge orders, leading clinical huddles, and facilitating seamless transitions through patient consent, device provisioning, and comprehensive education. You will act as the primary point of contact for patients and interdisciplinary healthcare teams, ensuring that every transition plan is meticulously documented in the electronic medical record and tailored to the patient's specific home health needs.

To be successful in this role, you will possess sharp clinical judgment and the ability to bridge the gap between hospital-based care and long-term outpatient recovery. You will demonstrate proficiency in EPIC documentation and have the interpersonal skills necessary to build rapport with patients during bedside consultations. We are looking for a proactive, organized nursing professional who thrives in a collaborative environment-partnering with Case Management, nursing staff, and physicians to drive the goals of the RHTP grant and provide the education necessary to ensure long-term health success for our rural patient population.

Job Requirements

RN License

BLS Certification

1-3 years Clinical RN experience in an acute care setting

Bachelor Degree preferred

Where You'll Work

Established by the Sisters of the St. Francis in 1924, CHI Health Good Samaritan is a 268-bed regional referral center in Kearney, Neb. At CHI Health Good Samaritan, you'll find an advanced level trauma center that also offers AirCare emergency helicopter transport and an ambulance program providing long distance and local 911 service. Among our many other services are cardiac care including open-heart surgery, a level II neonatal intensive care unit, a nationally accredited cancer center, comprehensive neurosurgery, advanced orthopedic program, and inpatient and outpatient mental health services at our free-standing Richard Young Behavioral Health facility.