Community Transition Nurse (Part-Time)

Job Description

Job Description

Position Summary

Circle of Care is seeking a compassionate and experienced nurse (RN or LPN) to support individuals transitioning from nursing facilities to community living. This role focuses on options counseling and post-discharge community visits, helping participants make informed decisions and remain safe and stable in the community.

This is a part-time, flexible position (up to 20 hours per week) designed for a nurse who values meaningful, person-centered work without the demands of full case management.

Schedule & Compensation

• Part-Time: Up to 20 hours per week (based on caseload)
• Flexible schedule based on participant needs and visit requirements

Core Responsibilities 1. Options Counseling

• Conduct in-person options counseling sessions with nursing facility residents
• Educate participants and families on community living options, services, and supports
• Support informed, person-centered decision-making
• Complete required Options Counseling documentation and obtain signatures within required timeframes

2. Welcome Visit (Post-Approval Engagement)

• Schedule initial participant contact within 2 business days of approval
• Conduct a face-to-face “Welcome Visit” within 5 business days of approval
• Establish rapport, assess immediate needs, and support transition readiness

3. Community Case Management Visits

• Conduct post-discharge home visits using standardized visit documentation
• Monitor:
  • Medical and mental health status
  • Medication adherence
  • Service utilization and gaps
  • Personal care supports
  • Home safety and environment
  • Social and financial stability
• Identify risks and escalate concerns as needed

4. Visit Frequency Protocol

• Conduct visits:
  • Twice monthly for the first 90 days post-discharge
  • Monthly thereafter
• Increase visit frequency when clinically indicated

5. Clinical Monitoring & Support

• Identify changes in condition or risks to community placement
• Provide clinical insight and recommendations
• Communicate concerns to appropriate team members or providers

6. Documentation & Compliance

• Complete all documentation accurately and within required timeframes
• Maintain participant records in accordance with program standards
• Ensure confidentiality and compliance with HIPAA

7. Collaboration

• Communicate with nursing facility staff, community providers, and internal team members
• Participate in select discharge planning meetings when clinical input is needed

Scope of Role

This position focuses on options counseling and community-based monitoring only and does not include:

• Full transition coordination
• Housing placement
• Benefits processing
• Ongoing service coordination

Qualifications

• Active or retired Registered Nurse (RN) or Licensed Practical Nurse (LPN) license
• Minimum 2 years of experience in:
  • Case management
  • Discharge planning
  • Long-term care, home health, or community-based services
• Strong clinical assessment and communication skills
• Ability to work independently in a flexible, part-time role

Work Environment

• Community-based role with travel to nursing facilities and participant homes
• Combination of fieldwork and documentation time
• Flexible scheduling

Key Characteristics for Success

• Compassionate and participant-centered
• Organized and self-directed
• Strong clinical judgment
• Comfortable working in a flexible, variable-hour role

About Circle of Care

Circle of Care is committed to improving the health, independence, and quality of life for older adults and individuals with disabilities through innovative, community-based programs and services.

Apply today to be part of a mission-driven team supporting safe and successful transitions to community living.

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