Transition Nurse

Health Link Home Health & Hospice is seeking an experienced Licensed Vocational Nurse (LVN) to join our growing Transitions Department.

The Transitions Nurse works closely with our Home Health clinical teams to identify patients whose healthcare needs are changing and help connect them with the appropriate level of care, services, and support. This may include hospice, palliative care, additional caregiving support, higher levels of care, placement, or other community resources based on the patient’s individual needs.

The Transitions Nurse serves as a consistent resource for patients and families throughout these changes, providing education, guidance, coordination, and follow-up to help ensure patients receive the right care at the right time.

A key component of the role includes recognizing patients who may benefit from hospice evaluation, providing hospice education and informational visits, and coordinating with the clinical team to facilitate timely transitions when appropriate.

JOB REQUIRES ON-SITE AND FIELD-BASED WORK

Key Responsibilities

• Work closely with Home Health clinicians to identify patients whose healthcare needs are changing and may require additional services or a different level of care.
• Proactively contact patients and families to identify changing needs, provide education, discuss available resources, and coordinate appropriate follow-up.
• Assist patients and families in navigating transitions to hospice, palliative care, additional caregiving support, higher levels of care, placement, or other appropriate community resources.
• Maintain ongoing communication and follow-up with patients and families throughout the transition process to help ensure identified needs are addressed.
• Collaborate with Home Health nurses, therapists, and clinical leadership to recognize patients who may benefit from hospice evaluation and ensure timely follow-up.
• Provide in-person informational sessions to patients, families, and caregivers regarding hospice care, services, benefits, and available resources.
• Support and coordinate seamless transitions from Home Health to Hospice when appropriate.
• Educate Home Health teams on recognizing changing patient needs, available transition resources, and when concerns should be escalated for further clinical evaluation.
• Provide hospice education and in-services to Home Health teams and community healthcare partners.
• Collaborate with physicians, nurses, therapists, social workers, Hospice staff, and other healthcare professionals to support appropriate and timely transitions.
• Communicate changes in patient condition or concerns regarding level of care to the appropriate RN, physician, or clinical leadership for further evaluation.
• Serve as a consistent point of contact for patients and families throughout changes in their healthcare needs.
• Maintain accurate and timely documentation of patient and family communication, follow-up activities, resources provided, and transition status.

Qualifications

• Current and unrestricted California Licensed Vocational Nurse (LVN) license.
• Minimum of 1 year of nursing experience, with Home Health, Hospice, palliative care, care transitions, or care coordination experience preferred.
• Knowledge of hospice, palliative care, and end-of-life care principles.
• Ability to recognize and communicate changes in patient condition and care needs to the appropriate clinical team.
• Excellent communication and interpersonal skills, including the ability to have sensitive conversations with patients and families.
• Strong organizational, follow-up, and care coordination skills.
• Ability to work independently while collaborating effectively with multidisciplinary teams.
• Comfortable providing education and presentations to clinical teams and community partners.
• Valid driver’s license and reliable transportation for patient and community visits.

Pay Range

LVN: $40–$45/hour

Benefits

• Health, Dental, and Vision Insurance
• 401(k) with matching
• Life Insurance
• Paid Time Off (PTO)
• Flexible Schedule
• Flexible Spending Account (FSA)