LifeLong Medical Care

  • Care Transitions Nurse - Kaiser Program

    Job Locations US-CA-San Pablo
    Posted Date 4 weeks ago(4 weeks ago)
    # of Openings
  • Overview

    LifeLong Medical Care has an exciting opportunity for an outstanding Care Transitions Nurse – Kaiser Program to join the team in Contra Costa County! This is a full time benefited position. The Care Transitions Nurse (CTRN) is part of a patient-centered team focused on coordination of care for patients in transition between the hospital and the primary care setting. Primary responsibilities include communication with hospital based and health plan based care teams (clinicians and case managers) and the site based clinical teams to coordinate patient transitions between levels of care. The CTRN also provides direct supervision for program c, transitioning homeless adults from hospital to temporary shelter placements, as well as overseeing the Emergency Department Navigator, aimed at reducing low level ED visits at Alta Bates Summit.

    LifeLong Medical Care is a large, multi-site, Federally Qualified Health Center (FQHC) with a rich history of providing innovative healthcare and social services to a wonderfully diverse patient community. Our patient-centered health home is a dynamic place to work, practice, and grow. We have 16 primary care health centers and deliver integrated services including psychosocial, referrals, chronic disease management, dental, health education, home visits, and much, much more. LifeLong Medical Care is an Equal Opportunity Employer.


    We offer excellent benefits including: medical, dental, vision (including dependent and domestic partner coverage), generous leave benefits including nine paid holidays, Flexible Spending Accounts, 403(b) retirement savings plan.  


    • Maintain accurate tracking list of all LifeLong assigned patients utilizing services at Kaiser Richmond hospital.
    • Conduct medication reconciliation. Compare transfer orders to previous hospital orders as well as the client’s list of home medications.
    • Maintain access to the established lists of high risk clients through health plan portal or other confidential site.
    • Supervise Community Health Workers in day to day management of Care Transitions patients.
    • Communicate clearly with patients about care plans. Ensure timely and appropriate hospital follow up and medical appointments.
    • Notify LifeLong staff as appropriate when patients are admitted to local hospitals.
    • Review hospital charts and notify primary care providers of important medical and social issues during hospitalization
    • Coordinate with LifeLong leadership and CHCN to organize, track, and report data.
    • Represent LifeLong in care transitions work group meetings with outside agencies.
    • Provide data statistics reports to Kaiser staff as outlined by the contract specification.


    • Commitment to the provision of primary care services for the underserved with demonstrated ability and sensitivity in working with a variety of people from low-income populations, with diverse educational, lifestyle, ethnic and cultural origins.
    • Ability to exercise sound clinical judgment independently.
    • Able to build relationships with key stakeholders in collaborating hospitals, as well as our own primary care team.
    • Ability to effectively supervise staff and to contribute to staff development.
    • Demonstrate comfort working with homeless and/or substance abusing patient in a supportive and non-judgmental manner.
    • Strong organizational, administrative and problem-solving skills, and ability to be flexible and adaptive to change.
    • Ability to seek direction/approval on essential matters, yet work independently with little onsite supervision, using professional judgment and diplomacy.
    • Work in a team-oriented environment with a number of professionals with different work styles and support needs.
    • Excellent interpersonal, verbal, and written skills Conduct oneself in external settings in a way that reflects positively on LifeLong Medical Care as an organization of professional, confident and sensitive staff.
    • Ability to see how one’s work intersects with that of other departments of LifeLong Medical Care and that of other partner organizations.

    Job Requirements          

    • Bachelor’s Degree in Nursing.
    • Bilingual English/Spanish
    • Current and valid CA RN license and current BLS.
    • Minimum two years’ clinical experience, especially in the area of chronic care management in a community health care setting.
    • Access to reliable transportation and current auto insurance (local travel will be required).
    • Proficient in Microsoft office suite.

    Job Preferences

    • Master’s Degree in Nursing or healthcare related field.
    • Supervisory experience
    • Experience with homelessness substance abuse, and psychiatric disorders.
    • Experience as part of a team-based care model and community health care settings.


    Sorry the Share function is not working properly at this moment. Please refresh the page and try again later.
    Share on your newsfeed