Community Transition Program Pps Jobs in Usa

Join VitalCaring Where Your Passion Changes Lives!

Are you looking for a career where compassion meets purpose? At VitalCaring, we're more than a home health and hospice providerwe're a family that supports, inspires, and uplifts both our patients and our team members.

Founded in 2021, VitalCaring has grown into a leading provider of home health and hospice services, with over 100 locations across the country. We are committed to fostering a culture of support, growth, and excellence for our team that is the backbone of how we ensure we deliver exceptional patient care.

Drive Innovation. Deliver Impact - Join a mission-driven team where your work directly contributes to advancing patient care. As a key player in a forward-thinking healthcare organization, you'll represent innovative solutions that truly make a difference for patients and familiestoday and into the future

Make a Meaningful Impact Help patients and families navigate their healthcare journey with compassion and dignity. Thrive in a Supportive Team Work with a team who genuinely care and invest in your success. Grow Your Career Take advantage of advanced training, mentorship, and career development opportunities. Competitive Pay & Benefits Be rewarded for your dedication and expertise with a compensation package that truly reflects your value. Our benefits are thoughtfully designed to support your well-beingoffering the flexibility, security, and resources you need to thrive both at work and in life. We celebrate success at every level, with meaningful recognition for both individual contributions and team achievements.

Health & Wellness Medical, Dental & Vision Pharmacy Benefits Virtual & Mental Health Support Flexible Spending Accounts (FSAs) & Health Savings Account (HSA) Supplemental Health & Life Insurance

Financial & Legal 401(k) with Company Match Employee Referral Program Prepaid Legal Plans Identity Theft Protection

Work-Life Balance & Perks Paid Time Off Pet Insurance Tuition & Continuing Education Reimbursement

Join VitalCaring Group and experience a company that invests in you every step of the way!

Job Summary

At VitalCaring, our team members transform lives and foster hope through genuine caring. As a Care Transition Navigator (CTN), you play a critical role in ensuring a safe, seamless transition from the acute care setting to home. You will conduct bedside assessments, identify high-risk medical and social needs, collaborate with hospital care teams, and coordinate timely, effective home health referrals. This role is essential to preventing avoidable rehospitalizations while delivering a compassionate, patient-centered experience. Every encounter reflects our valuestrustworthy, capable, compassionate, proactive, and called.

Essential Functions

Clinical Assessment & Care Coordination

• Conduct onsite hospital bedside assessments within 24 hours of referral.
• Integrate evidence-based clinical guidelines to develop patient-centered transition plans.
• Engage with patients, caregivers, case managers, physicians, and inpatient teams to gather key information for discharge planning.
• Identify high-risk medical and social determinants of health needs and communicate them to the care team.
• Schedule a follow-up primary care appointment within 3 days post-discharge.
• Complete follow-up phone calls within 48 hours of discharge and document CTN Follow-Up Coordination notes in HCHB.
• Support strategies to reduce home health rehospitalizations through proactive communication and interventions.

Documentation & EMR Responsibilities

• Document CTN coordination notes to support admitting home health clinicians.
• Complete workflow tasks and assignments specific to the CTN role in the EMR.
• Receive and enter verbal orders in HCHB from licensed practitioners and ensure physician approval.
• Follow up on pending referrals to support timely home health admissions.

Interdisciplinary Collaboration

• Participate in care coordination with agency staff, contractors, patients, and referral partners.
• Communicate effectively with all providers involved in a patient's plan of care.
• Educate patients and caregivers on engagement with the VitalCaring Connection (VCC) for virtual and telephonic care.
• Prepare for and participate in case conferences with other healthcare team members.

Professional Standards

• Meet all mandatory continuing education requirements.
• Demonstrate effective communication and interpersonal skills across the care team.
• Attend agency-sponsored in-service training sessions.
• Perform additional duties as assigned.

Qualifications

Education & Licensure

• Graduate of an accredited nursing program (RN, LVN/LPN) or an accredited Physical Therapy program (PT).
• Active RN, LVN/LPN, or PT license in state of employment; valid driver's license required.
• May require completion of HHS Computer-Based Training depending on license category.

Experience & Skills

• Minimum of two years of clinical experience as an RN, PT, LVN, or LPN.
• One year of home health experience preferred.
• Strong nursing or PT clinical skills aligned with accepted standards of practice.
• Excellent interpersonal, communication, and decision-making skills.
• Proven relationship-building and territory management abilities.
• Proficiency with Microsoft Office, CRM platforms, and EMR systems preferred.

Additional Requirements

• Reliable transportation with current auto liability insurance.
• Ability to work a flexible schedule, including weekends based on referral partner needs.
• Comfortable spending 80% of time in assigned hospital or facility settings.

Do you have the PRN career opportunities as a RN Student Nurse Extern PRN Senior Transition you want with your current employer? We have an exciting opportunity for you to join Chippenham Hospital which is part of the nation's leading provider of healthcare services, HCA Healthcare.

Chippenham Hospital, offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:

• Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as telemedicine services and free AirMed medical transportation.
  
• Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.
  
• Fertility and family building benefits through Progyny
  
• Free counseling services and resources for emotional, physical and financial wellbeing
  
• Family support, including adoption assistance, child and elder care resources and consumer discounts
• 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)
• Employee Stock Purchase Plan
  
• Retirement readiness and rollover services and preferred banking partnerships
  
• Education assistance (tuition, student loan, certification support, dependent scholarships)
  
• Colleague recognition program
  
• Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)
  

Learn more about Employee Benefits

Note: Eligibility for benefits may vary by location.

Our teams are a committed, caring group of colleagues. Do you want to work as a RN Student Nurse Extern PRN Senior Transition where your passion for creating positive patient interactions is valued? If you are dedicated to caring for the well-being of others, this could be your next opportunity. We want your knowledge and expertise!

The Nurse Extern PRN will work under the supervision of the Registered Nurse (RN), and assist the nursing staff in providing patient care. You will deliver high quality, patient-centered care services related to common nursing functions and activities of daily living.

· You will work closely with the clinical team to create and implement a care plan by performing direct and indirect patient care under the supervision of the licensed nurse.

· Obtain and record initial and ongoing patient information throughout the cycle of care.

· You will assist with patient mobility by regularly turning, positioning, and ambulating as well as transferring patients to and from other units/departments.

· Translate complex medical terminology to ensure patients/families/caregivers understand patient medical condition, treatment plan, medications and possible side effects and follow up measures

· Educate patients/families/caregivers on healthy diet, exercise, disease prevention and/or lifestyle changes that may be needed upon discharge and prepares for future self-management

· Currently enrolled and in good standing in an accredited school of nursing required and can perform higher-level procedures once competency is achieved.

· Possess the ability to create and implement a personal career development plan, to be reviewed regularly by supervisor and/or preceptor

· One year of completed nursing school is preferred

· Basic Life Support (BLS) certification.

Chippenham Hospital has provided quality healthcare services since 1972, giving patient's access to highly-trained physicians and advanced technology. With more than 50 years of pioneering healthcare, our 460+ bed hospital is one of the region's leading acute care facilities located on the Southside of Richmond. We are the region's first choice for orthopedics, joint care, behavioral health and cardiovascular care. The Joint Commission awarded Chippenham Hospital the Gold Seal of Approval and named us a Top Performer on Key Quality Measures for advanced primary stroke, heart attack, heart failure, pneumonia, perinatal care, hip and knee replacement and surgical care. We are also a Level I Burn Center and Level I Trauma Center.

If you are looking for an opportunity that provides satisfaction and personal growth, we encourage you to apply for our RN Student Nurse Extern PRN Senior Transition opening. We review all applications. Qualified candidates will be contacted for interviews. Unlock the possibilities and apply today!

We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status

• 
  
• Medical: Multiple plan options.
  
• Dental: Delta Dental or reimbursement account for flexible coverage.
  
• Vision: Affordable plan with national network.
  
• Pre-Tax Savings: HSA and FSAs for eligible expenses.
  
• Retirement: Competitive retirement package to secure your future.
  

The registered nurse (RN) is accountable for the coordination of nursing care, including direct patient care, patient/family education and transitions of care. The RN supports professional nursing practice across practice settings and across the continuum of care to meet the needs of the patient and family. The RN will function within the Mayo Clinic Nursing Professional Practice Model, which includes accountability for planning, implementing, evaluating and communicating all phases of nursing care for assigned patients. The ANA Nursing: Scope and Standards of Practice provide a basis for the practice of the RN. The RN provides leadership through activities such as preceptor role, informal leadership roles, and quality improvement efforts. The RN delegates patient care according to skill level, experience, patient acuity, fiscal accountability, and adequacy of resources. The RN possesses excellent communication skills; is skillful in mentoring and teaching; and may participate on committees or projects. A subset of employees may be required to drive their personal vehicle as a part of the responsibility of their role. 

This role is eligible for TN sponsorship. Successful sponsorship will require state licensure and completion of the VisaScreen or equivalent certification.

Graduate of a nursing program.

All entry-level associate degree registered nurses with a RN start date of April 1, 2020 and after must provide documented evidence of program completion of a baccalaureate degree in nursing program within five years from the last day of the month of the RN start date.

All entry-level associate degree registered nurses with a RN start date prior to April 1, 2020 must provide documented evidence of program completion of a baccalaureate degree in nursing program as stipulated by the degree requirement program in place at time of hire.

One year of RN experience in an applicable care setting or one year of LPN experience at Mayo Clinic is preferred.

Excellent communication skills (verbal and written). Experience working in a team environment. Computer skills required, prior experience with electronic medical record systems preferred. Ability to work flexible hours, which may include days, evenings, nights, holidays, and weekends and on-call. Ability to adapt to unpredictable situations within the work setting. Demonstrated leadership, effective communicator, and excellent critical thinking skills.

License or Certification: Current RN license by applicable state requirements. Maintains Basic Life Support (BLS) competency from one of the following programs: American Heart Association or American Red Cross. Positions that are not on campus may not require current Basic Life Support (BLS) competency as determined by the work area.

Additional state licensure(s) and/or specialty certification/training as required by the work area.
 

• 
  
• Medical: Multiple plan options.
  
• Dental: Delta Dental or reimbursement account for flexible coverage.
  
• Vision: Affordable plan with national network.
  
• Pre-Tax Savings: HSA and FSAs for eligible expenses.
  
• Retirement: Competitive retirement package to secure your future.
  

The registered nurse (RN) is accountable for the coordination of nursing care, including direct patient care, patient/family education and transitions of care. The RN supports professional nursing practice across practice settings and across the continuum of care to meet the needs of the patient and family. The RN will function within the Mayo Clinic Nursing Professional Practice Model, which includes accountability for planning, implementing, evaluating and communicating all phases of nursing care for assigned patients. The ANA Nursing: Scope and Standards of Practice provide a basis for the practice of the RN. The RN provides leadership through activities such as preceptor role, informal leadership roles, and quality improvement efforts. The RN delegates patient care according to skill level, experience, patient acuity, fiscal accountability, and adequacy of resources. The RN possesses excellent communication skills; is skillful in mentoring and teaching; and may participate on committees or projects. A subset of employees may be required to drive their personal vehicle as a part of the responsibility of their role. 

This role is eligible for TN sponsorship. Successful sponsorship will require state licensure and completion of the VisaScreen or equivalent certification.

Graduate of a nursing program.

All entry-level associate degree registered nurses with a RN start date of April 1, 2020 and after must provide documented evidence of program completion of a baccalaureate degree in nursing program within five years from the last day of the month of the RN start date.

All entry-level associate degree registered nurses with a RN start date prior to April 1, 2020 must provide documented evidence of program completion of a baccalaureate degree in nursing program as stipulated by the degree requirement program in place at time of hire.

One year of RN experience in an applicable care setting or one year of LPN experience at Mayo Clinic is preferred.

Excellent communication skills (verbal and written). Experience working in a team environment. Computer skills required, prior experience with electronic medical record systems preferred. Ability to work flexible hours, which may include days, evenings, nights, holidays, and weekends and on-call. Ability to adapt to unpredictable situations within the work setting. Demonstrated leadership, effective communicator, and excellent critical thinking skills.

License or Certification: Current RN license by applicable state requirements. Maintains Basic Life Support (BLS) competency from one of the following programs: American Heart Association or American Red Cross. Positions that are not on campus may not require current Basic Life Support (BLS) competency as determined by the work area.

Additional state licensure(s) and/or specialty certification/training as required by the work area.
 

• 
  
• Medical: Multiple plan options.
  
• Dental: Delta Dental or reimbursement account for flexible coverage.
  
• Vision: Affordable plan with national network.
  
• Pre-Tax Savings: HSA and FSAs for eligible expenses.
  
• Retirement: Competitive retirement package to secure your future.
  

The registered nurse (RN) is accountable for the coordination of nursing care, including direct patient care, patient/family education and transitions of care. The RN supports professional nursing practice across practice settings and across the continuum of care to meet the needs of the patient and family. The RN will function within the Mayo Clinic Nursing Professional Practice Model, which includes accountability for planning, implementing, evaluating and communicating all phases of nursing care for assigned patients. The ANA Nursing: Scope and Standards of Practice provide a basis for the practice of the RN. The RN provides leadership through activities such as preceptor role, informal leadership roles, and quality improvement efforts. The RN delegates patient care according to skill level, experience, patient acuity, fiscal accountability, and adequacy of resources. The RN possesses excellent communication skills; is skillful in mentoring and teaching; and may participate on committees or projects. A subset of employees may be required to drive their personal vehicle as a part of the responsibility of their role. 

This role is eligible for TN sponsorship. . Successful sponsorship will require state licensure and completion of the VisaScreen or equivalent certification.

Graduate of a nursing program.

All entry-level associate degree registered nurses with a RN start date of April 1, 2020 and after must provide documented evidence of program completion of a baccalaureate degree in nursing program within five years from the last day of the month of the RN start date.

All entry-level associate degree registered nurses with a RN start date prior to April 1, 2020 must provide documented evidence of program completion of a baccalaureate degree in nursing program as stipulated by the degree requirement program in place at time of hire.

One year of RN experience in an applicable care setting or one year of LPN experience at Mayo Clinic is preferred.

Excellent communication skills (verbal and written). Experience working in a team environment. Computer skills required, prior experience with electronic medical record systems preferred. Ability to work flexible hours, which may include days, evenings, nights, holidays, and weekends and on-call. Ability to adapt to unpredictable situations within the work setting. Demonstrated leadership, effective communicator, and excellent critical thinking skills.

License or Certification: Current RN license by applicable state requirements. Maintains Basic Life Support (BLS) competency from one of the following programs: American Heart Association or American Red Cross. Positions that are not on campus may not require current Basic Life Support (BLS) competency as determined by the work area.

Additional state licensure(s) and/or specialty certification/training as required by the work area.
 

Were unique. You should be, too.

Were changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy?

Were different than most primary care providers. Were rapidly expanding and we need great people to join our team.

The Community Care team is a multidisciplinary service including Registered Nurse (RN) Community Care nurses, Licensed Practical Nurse (LPN) Community Care nurses, Community Social Workers (CSW) and Community Health Coordinator (CHC) who work with our highest complexity patients and their primary care physicians to meet their medical and social needs with the aims of fully engaging them in our intensive primary care model and maximizing their healthy time at home.

ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

• Provides in home and telephonic visits to patients at high-risk for hospital admission and readmission (as identified by CM Plan). Main goal to prevent and admission or readmission to the ER/hospital .
• Provides home visits to perform initial assessment of patient and the development of care plan for the Licensed Practical Nurse (LPN) to use as they perform the follow up patient visits, once patient has completed their episode of care management the register nurse (RN) will review patient chart for discharge and conduct final discharge with patient.
• Conducts supervisory visits with License Practical Nurse (LPN) and patient to provide any additional education patient may need and to oversee appropriate patient discharge from case management.

• Performs clinical and Social determination of Heath screening (SdoH) assessments to include disease-oriented assessment and monitoring, medication monitoring, health education and self-care instructions in the outpatient in home setting.

Coordinate the Plan of Care:

• Provides oversight for the License Practical Nurse (LPN) with clear plan of care and education which is mandatory during all LPN visits.
• Conducts/coordinates initial case management assessment of patients to determine outpatient needs.
• Ensures individual plan of care reflects patient needs and services available in the community or review of their benefits.
• Completes individual plan of cares with patients, family/care giver and care team members.
• Communicates instructions and methodologies as appropriate to ensure that the plan is implemented correctly.
• Assesses the environment of care, e.g., safety and security.
• Assesses the caregiver capacity and willingness to provide care.
• Assesses patient and caregiver educational needs.
• Coordinates, reports, documents and follows-up on multidisciplinary team meetings.
• Helps patients navigate health care systems, connecting them with community resources; orchestrates multiple facets of health care delivery and assists with administrative and logistical tasks.
• Coordinates the delivery of services to effectively address patient needs.
• Facilitates and coaches patients in using natural supports and mainstream community resources to address supportive needs.
• Maintains ongoing communication with families, community providers and others as needed to promote the health and well-being of patients.
• Establishes a supportive and motivational relationship with patients that support patient self-management
• Monitors the quality, frequency, and appropriateness of HHA visits and other outpatient services.
• Assists patient and family with access to community/financial resources and refer cases to social worker as appropriate.
• Home visit under the direction of the patients primary care physician to meet urgent patient needed.
• Performs other duties as assigned and modified at managers discretion.

EDUCATION AND EXPERIENCE CRITERIA:

• Associate degree in Nursing required.
• Bachelors Degree in nursing (BSN) or RN with bachelors degree in home in a related clinical field preferred.
• A valid, active Registered Nurse (RN) license in State of employment required.
• A minimum of 2 years clinical work experience required.
• A minimum of 1 year of case management experience in community case management experience highly desired.
• Certified Case Manager certification is preferred. Certification through the Commission for Case Manager Certification (CCMC) or the American Association of Managed Care Nurses (CMCN) desired
• This position requires possession and maintenance of a current, valid drivers license.
• Basic Life Support (BLS) certification from the American Heart Association (AMA) or American Red Cross required w/in first 90 days of employment

PAY RANGE:

$35.8 - $51.17 Hourly

EMPLOYEE BENEFITS

Were ChenMed and were transforming healthcare for seniors and changing Americas healthcare for the better. Family-owned and physician-led, our unique approach allows us to improve the health and well-being of the populations we serve. Were growing rapidly as we seek to rescue more and more seniors from inadequate health care.

ChenMed is changing lives for the people we serve and the people we hire. With great compensation, comprehensive benefits, career development and advancement opportunities and so much more, our employees enjoy great work-life balance and opportunities to grow. Join our team who make a difference in peoples lives every single day.

Current Employee apply HERE

Current Contingent Worker please see job aid HERE to apply

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Job Title: Healthcare Marketing and Hospital Liaison

Location: Marion, Ohio 

Position Summary

The Marketing and Hospital Liaison represents Marion Rehabilitation within the Marion-area healthcare community. This position plays a key role in promoting the facility’s skilled nursing and rehabilitation services, cultivating strong referral relationships, and supporting community engagement. The liaison will regularly visit area hospitals to meet with patients, families, and discharge planners, ensuring a smooth transition of care and positive representation of Garden Springs Healthcare.

Key Responsibilities

Hospital & Referral Relations

• Represent Marion Rehabilitation at Marion-area hospitals, serving as the primary contact for discharge planners, case managers, and other healthcare professionals.
• Conduct hospital visits to assess potential residents, explain services, and coordinate admissions in collaboration with the internal admissions team.
• Build and maintain strong relationships with hospitals, physicians, and other referral partners to drive census growth and strengthen referral pipelines.

Community Engagement

• Plan, organize, and host community-based events both on and off site to promote Marion Rehabilitation's services and enhance community visibility.
• Represent the facility at local health fairs, senior events, and networking functions.
• Develop partnerships with community organizations, senior centers, and civic groups to foster ongoing engagement.

Marketing & Outreach

• Collaborate with facility leadership to develop and implement outreach and marketing strategies that support census and growth goals.
• Maintain marketing materials and ensure consistent branding and messaging.
• Track referral trends, admissions, and outreach efforts, providing regular updates to leadership.

Customer Service & Communication

• Demonstrate professionalism, empathy, and responsiveness in all interactions with patients, families, and referral partners.
• Ensure timely communication and follow-up throughout the referral and admission process.
• Promote a positive image of Garden Springs Healthcare in all external and internal communications.

Qualifications

• Experience in healthcare marketing, hospital liaison, or admissions role (skilled nursing, rehab, or post-acute care required).
• Strong relationship-building and communication skills.
• Knowledge of Marion & Columbus-area hospitals and healthcare networks required.
• Ability to work independently, prioritize effectively, and meet deadlines.
• Valid driver’s license and reliable transportation required.

Required Skills

• Experience planning and hosting community events.
• Familiarity with Medicare/Medicaid and discharge planning processes.
• Excellent organizational, communication, and presentation skills.