Registered Nurse, Care Transitions

Accompany Health is on a mission to give patients with complex needs the dignified, high-quality care they deserve but rarely receive. A primary, behavioral, and social care provider, Accompany Health walks alongside patients for their entire care journey, offering at-home and virtual care, as well as 24/7 support. Partnering with innovative payors, Accompany Health is powered by remarkable care teams, elegant technology, and a commitment to evidence-based practice. We build long-term relationships with our patients so they know, without question, that our team is here for them day or night, year after year. We focus on the health outcomes most important to our patients to make it clear that they lead the way. To achieve our mission, we collaborate with community-based organizations, local providers, and health plans. Led by our empathetic care teams, guided by proven care models, and powered by our own technology, we deliver a level of service that our communities rightfully deserve but rarely receive. While our headquarters is in Bethesda, MD, our teams are distributed across the country. If you’re eager to make a tangible difference in people’s lives, to help correct long-standing disparities in health care, join us. About the role: As the Registered Nurse, Care Transitions, you will be at the forefront of delivering seamless, high-impact care for patients with complex medical, behavioral health, and social needs. In this pivotal role, you will champion safe, coordinated transitions across care settings—helping patients stay healthy at home, reduce avoidable hospitalizations, and experience truly continuous, high-quality care. You will serve as a vital connector between post-acute transitions and ongoing, integrated nursing support, ensuring patients feel supported, informed, and empowered every step of the way. This is an opportunity to make a tangible difference in patients’ lives while practicing at the top of your license. You’ll join a collaborative, mission-driven multidisciplinary team that includes Physicians, Advanced Practice Clinicians, Health Advocates, Social Workers, Behavioral Health Clinicians, Psychiatrists, Pharmacists, and Patient Experience Navigators. Working closely with both local and centralized teams, you’ll deliver patient-centered care through a blend of virtual and telephonic services tailored to meet each patient’s unique needs. As our innovative care model continues to grow and evolve, this role offers the opportunity to grow with it, helping shape the future of integrated, home-based care. Responsibilities will include: Essential Functions • Provide post-discharge transitions of care support in order to reduce readmissions, rehospitalizations and ED revisits for patients recently discharged from emergency departments, hospitals, skilled nursing facilities, or behavioral health facilities. This includes: • Completing a RN visit and/or interaction within 7 days of discharge • Performing clinical assessments, identifying red flags, and appropriately escalating to urgent care and/or supervising physicians when needed for patients at risk of decompensation and/or readmission • Ensuring accurate medication reconciliation post-discharge, with appropriate medications in-hand and adherence to medication plan • Scheduling and ensuring completion of a post-discharge visit with an AH provider within 7 days of discharge date for patients discharged from inpatient, observation, or SNF admissions • Providing appropriate patient education, coaching and self-management support • Identifying clinical, behavioral, and social barriers to recovery or stability and coordinate appropriate follow-up care and referrals • Providing patient remote monitoring support when needed to ensure recovery and preve