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Transition of Care Registered Nurse
Job Description
Position Type: Contact Full Time
Job Title: Transition of Care Registered Nurse
Location: San Diego, CA (Remote position but will require some travel. Must have a valid CA Driver's License)
Duration: 03+ Months
Offered Rate: $ 42.80/Hrs. On W2(All Inclusive)
Schedule: M-F 8: 30-5: 30 PST
Job Responsibilities:
o Follows member throughout a 30-day program that starts at hospital admission and continues through transitions from the acute setting to other settings, including nursing facility placement and private home, with the goal of reduced readmissions.
o Ensures safe and appropriate transitions by collaborating with hospital discharge planners, as well as with hospitalists, outpatient providers, facility staff, and family/support network, as needed or at the request of member.
o Ensures member transitions to a setting with adequate caregiving and functional support, as well as medical and medication oversight as required.
o Works with participating ancillary providers, public agencies, or other service providers to make sure necessary services and equipment are in place for a safe transition.
o Conducts face-to-face visits of all members while in the hospital and home visits of high-risk members’post-discharge.
o Coordinates care and reassesses member's needs using the Coleman Care Transitions Model recommended post-discharge timeline.
o Educates and supports member focusing on seven primary areas (ToC Pillars): medication management, use of personal health record, follow up care, signs and symptoms of worsening condition, nutrition, functional needs and or Home and Community-based Services, and advance directives.
o Uses motivational interviewing and clinical guideposts to educate, support and motivate change during member contacts.
o Assesses for barriers to care, provides care coordination and assistance to member to address concerns.
o Facilitates interdisciplinary care team meetings and informal ICT collaboration.
o RNs provide consultation, recommendations, and education as appropriate to non-RN case managers.
o RNs are assigned cases with members who have complex medical conditions and medication regimens.
o RNs will conduct medication reconciliation when needed.
o 5-10% local travel required.
Top Skills Required:
o Discharge planning experience
o Motivational Interviewing
o Team player
Required Education/Certification(s):
o Registered Nurse
Required Years of Experience:
o 3-5 minimum
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Staffing Leader of the Year Anju Abel
CEO, LanceSoft
LanceSoft is proud to announce that its Chief Executive Officer, Anju Abel, has been honored with the prestigious "Staffing Leader of the Year" award at the 2025 TIARA Staffing Awards US. The award recognizes her visionary leadership and significant contributions to improving staffing processes, employee engagement, and workforce outcomes.
Anju Abel's leadership has been instrumental in transforming LanceSoft's global staffing operations. Her focus on innovation, employee satisfaction, and client-centric delivery has led to higher retention rates, a motivated workforce, and enhanced operational efficiency.
"This award is a testament to the incredible team at LanceSoft and our unwavering commitment to redefining staffing solutions," said Anju Abel. "I'm honored to receive this recognition and proud of the impact we continue to make in the lives of our clients and talent worldwide."
The judging panel highlighted Anju's ability to consistently deliver outstanding client success stories, exceed expectations, and foster professional development within her team. Her active community involvement and dedication to advancing the staffing industry were also key factors in her selection.
TIARA Awards are known for celebrating excellence, innovation, and achievement in the talent acquisition sector, and this accolade places Anju among the top leaders reshaping the future of workforce solutions.