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Care Transition Nurse

Oakland, California
Job Type
12 Sep 2022
For over 40 years Pathways has been a Bay Area pioneer, leader, and innovator in Hospice, Home Health, Palliative Care, and Care Management services. We provide care at home or in settings such as assisted living, a nursing home, or the hospital. We have offices in Sunnyvale, South San Francisco, and Oakland. Patients and their families know us for our personalized, high-quality care, delivered with empathy, kindness, and respect.

TITLE: Care Transition Nurse
TERRITORY: Alameda County
SHIFT: M-F, some weekends

The Care Transition Nurse (CTN) makes essential contributions to the achievement of the organization's
objectives as a field-based business development representative, consistently meeting the volume
expectations for referrals and admissions. The CTN is expected to travel to various referral sources and potential patients and communicate Pathways Home Health and Hospice services, patient criteria and agency policies to secure appropriate contracts for patient care. This position collaborates with physicians, hospitals, nursing homes and home care personnel in the process of securing admissions for coordinated quality home based services for patients referred to CHI Health at Home. This activity may be in a health care facility or in the field office location.

1. Supports Pathways' mission to exceed the expectations of our customers, associates, and shareholders in the delivery of health care and support services in a way that a caring family provides. Supports Pathways' values, strategic goals and high standards of customer service. Consistently lives People First Behaviors. Follows the policies and procedures of the organization.
2. Adheres to the Corporate Compliance Program, including confidentiality HIPAA protected health
3. Must meet or exceed established monthly admission target(s) as provided by their supervisor and
determined by the branch monthly budget.
4. Identifies and qualifies health care relationships within regional territory with a focus on physicians,
hospitals, nursing homes and home care personnel, and other health care providers and hospital
3.2020 Page 2 of 5 Care Transition Nurse Job Description
systems as a source of referrals and admissions. The CTN is expected to make at least (tbd) site visits
each month to various health care providers and (tbd) telephone calls each month to health care
providers to expand the group of referral sources and sources for admissions.
5. Follows referral of a patient to Pathways, assists discharge coordinators in coordinating quality home
care services for clients in the following manner:
a. Determines patient eligibility for home care services and secures patient admissions.
b. Effectively communicates with appropriate disciplines involved in the care of potential home
care clients, and provides information and recommendations to Pathways staff.
c. Develops professional working relationships with health care providers and facilities, generating
an open flow of information and support of home care goals; provides value added counsel,
teaching and resourceful problem solving.
d. Available to all discharge planners, physicians, other hospital personnel and clients to 1) analyze
eligibility for home health or hospice and provide general guidance in determining if a patient
would benefit from home care or hospice services and/or 2) explain Medicare and Medicaid
guidelines, insurance plan benefits, financing options, CHI Health at Home policies, etc.
6. Upon patient choice of Pathways, communicates with attending physicians to obtain orders for home
health services.
7. Upon patient choice of Pathways determines individual patient needs for services, community
referrals, training and provides patient instructions on home care equipment and/or procedures, etc.
8. When requested, participates in the education of providers and personnel on home health regulations
and the variety of services available as well as industry trends.
9. When requested, participates in educating/in-servicing new providers and personnel on home health
or hospice and the importance of the communication of this information to their clients.
10. When requested, participates in hospital patient huddles or rounds to be a general home care resource
for patients choosing Pathways home health or hospice services.
11. Provides general home care or hospice education to patients, family and others as requested by
referral sources.
12. When a hospital contracts with Pathways for the CTN to perform the following services:
  • Presents patient with home health agencies and obtains patient's signed home care choice form.
  • Arranges home health services for patients regardless of agency selected.
13. Meets with the Director, Operations and other Pathways associates to ensure continuity of care for the
14. Maintains confidentiality regarding all patient, personnel, and institutional information.
15. Promotes effective working relationships with nursing personnel, the management team, and health
care providers
16. Functions in clinical areas which may include neonates, pediatrics, adolescents, adults, and geriatrics.
May interact directly with persons in the age categories of neonate, infant, child, adolescent, adult and
17. Works independently with limited direct supervision using the guidelines of the Nurse Practice Act,
Pathways and department policy and procedures, and professional judgment
18. The CTN observes and reports trends, changes, and new opportunities and identifies ways to educate
and advance providing home care as an optimal solution as appropriate. Thereby grows market share
in support of the business plans of Pathways.
19. Participates in Quality Assurance Performance Improvement (QAPI); including assisting with the overall
development and implementation of the PI plan, assisting in the identification of goals and related
patient outcomes, participation and reporting of activities and outcomes, development and
implementation of corrective plans.
20. Provides own transportation. Operates vehicle in a safe manner to perform required duties of the
21. All other duties assigned

  • Graduate of an accredited school of nursing.
  • Current RN, LPN, MSW, or BSW license to practice in the state serviced.
  • Two years of appropriate nursing experience is required.
  • Experience as a Care Transition Nurse or similar role, sales or marketing, or customer service preferred.
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