Intake RN - Care Transitions

Role Overview Avail Health is building a technology-enabled Care Transitions Program designed to support Medicare-age patients during one of the most vulnerable periods in their healthcare journey: the transition from hospital to home. The Intake RN serves as Avail Health's primary hospital-based clinical representative, identifying, assessing, and enrolling eligible patients into the Care Transitions Program prior to discharge. This role requires strong clinical judgment to evaluate patient complexity, anticipate post-discharge needs, determine program eligibility, support risk stratification, and recommend the appropriate care pathway and level of interdisciplinary support. Working closely with hospital care management teams, physicians, nurses, social workers, discharge planners, caregivers, and community partners, the Intake RN helps ensure high-risk Medicare patients receive the appropriate level of support during the transition from hospital to home while balancing program resources and team capacity. As a key member of a newly developing care model, this role also provides frontline insight that helps shape workflows, operational processes, and program growth. What You'll Own Patient identification, assessment, and enrollment into the Care Transitions Program Clinical assessment, eligibility determination, and risk stratification Care pathway and resource recommendations based on patient complexity Hospital stakeholder relationships and care coordination partnerships Seamless handoff of enrolled patients to Avail's interdisciplinary Care Transitions team Documentation, compliance, and operational excellence throughout the intake process Frontline feedback supporting workflow refinement and program development What You'll Do Participate in hospital huddles, rounds, discharge planning meetings, and care coordination activities to identify patients eligible for the Care Transitions Program Conduct bedside patient assessments and enrollment conversations Evaluate medical, behavioral health, psychosocial, caregiver, and environmental factors impacting successful transitions of care Determine program eligibility and appropriate risk stratification levels Recommend care pathways, visit modalities, and interdisciplinary team resources based on patient complexity and anticipated support needs Coordinate with caregivers, family members, and authorized representatives as appropriate Collaborate closely with Nurse Practitioners, RN Care Managers, Social Work Care Managers, Care Coordinators, and program leadership Facilitate timely information exchange between hospital and community-based care teams Connect patients with appropriate community resources and support services Maintain accurate documentation within hospital systems and Avail technology platforms Participate in workflow refinement and continuous process improvement efforts as the program evolves What Success Looks Like Appropriate patients consistently identified and enrolled before discharge Clinical assessments accurately reflect patient risk, complexity, and support needs Patients are connected to the appropriate level of services and resources Smooth transitions from hospital to home with minimal barriers or delays Strong relationships maintained with hospital stakeholders Patients, caregivers, and families understand and engage with post-discharge care plans Team capacity and program resources are utilized effectively through sound intake and triage decisions Accurate and timely documentation supporting continuity of care and compliance What You Bring Required Active, unrestricted Maryland RN license in good standing Minimum 5 years of clinical nursing experience Experience supporting transitions of care, discharge planning, care management, or complex care coordination for high-risk populations Experience providing care within patients' homes through home health, hospice, palliative care, house calls, community-based care management, or similar care models Demonstrated clinical judgment in patient assessment, triage, discharge planning, transitions of care, or complex care management settings Ability to independently evaluate patient complexity and anticipate post-discharge support needs Strong clinical assessment, critical thinking, and problem-solving skills Excellent communication and relationship-building skills Ability to manage multiple competing priorities within a fast-paced environment Strong organizational skills and attention to detail Preferred Hospital care management, discharge planning, transitions of care (TOC), transitional care management (TCM), or hospital readmission reduction experience Emergency Department, observation, triage, rapid assessment, or other high-acuity care coordination experience Experience working with Medicare-age populations with complex medical, behavioral health, or psychosocial needs Experience supporting startup healthcare organizations, new program launches, or rapidly evolving care delivery models Experience working with interdisciplinary care teams across clinical and operational functions Familiarity with technology-enabled care models and workflow-driven care delivery Schedule and Work Style Work Type: Primarily in-person, hospital-based Location: Rockville, Maryland area Schedule: Monday–Friday, standard business hours Travel: Occasional local travel for patient engagement and care coordination activities Autonomy: High. Functions independently within the hospital environment while collaborating closely with Avail's interdisciplinary Care Transitions team. Compensation and Perks Salary Range: $99,000–$120,000 annually, commensurate with experience Medical, dental, and vision insurance 401(k) with employer match Paid time off and company holidays Professional liability and malpractice coverage Technology and equipment provided Licensure support as applicable #J-18808-Ljbffr