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RN Transitional Health Coach

Position Summary:

Transitional Health Coach works to improve the outcomes of patients during the transition period from hospital-to-home.  Assesses plans, implements, coordinates, monitors and evaluates options and services to meet patient’s health needs through appropriate communications and utilization of available resources to promote quality, cost-effective outcomes. Via assessment of patient, the RN will develop and implement a Plan of Care based on utilization guidelines and Clinical Pathways.  The focus of service delivery is on providing the right mixes of services and service resources that result in the patient achieving the Plan of Care. Good communication skills to facilitate coordination of care.  Familiarity with decimals and metric system.  Proficient in use of OASIS.  Knowledge of OSHA, JCAHO/CHAP, State and Federal standards.  Familiar with payor reimbursement guidelines. Knowledge of standard precautions.   Must thoroughly understand PPS, be clinically astute, and utilize case management guidelines to promote positive outcomes, utilize automation effectively, and incorporate effective processes and collaboration.

Essential Duties & Responsibilities:

  • Work closely with hospital discharge planners and patients and their families in the hospital and follow-up at home and in physician offices
  • Performs patient admissions, resumption of care, follow-up using OASIS data collection in a timely, legible, accurate manner
  • Identifies, documents and reports signs and symptoms of altered health status to physician and Clinical Team Manager.  Obtains appropriate orders to increase/decrease visit frequency.  Obtains medical orders to alter treatment plan.
  • Develops Plan of Care consistent with clinical assessment findings, diagnosis, orders, HHRG Case Mix category, and appropriate utilization guidelines/clinical pathway specific to each patient.  Sets and evaluates attainable, specific, and measurable goals and outcomes.
  • Administers meds and treatment according to Plan of Treatment.
  • Teaches nursing care appropriate to patient’s condition.  Teaching based on patient/caregiver level of understanding and is properly reflected in records.
  • Coordinates care, integrating other health team members.  Participates in intra – disciplinary conferences as required.
  • Documents patient records according to agency policy.  Completes clinical notes, Plan of Care and medication records in a timely, legible and accurate manner. 
  • Notes progress towards discharge planning.  Communicates with physician, and appropriate staff regarding discharge planning.
  • Completes all discharge summaries according to policy and procedures.
  • Utilizes knowledge of nursing, biological, social science, PPS, case management guidelines, and collaborative resources within the agency as well as outside the agency to assist with the development and /or revision to the Plan of Care to promote positive outcomes.
  • Participates in back up call according to need of agency.
  • Demonstrates safety precautions in compliance with OSHA, JCAHO/CHAP, and Federal and State standards.
  • Operates medical equipment correctly for patient care.
  • Maintains current knowledge of nursing/home care as well as agency’s policies and procedures via in-services, testing, skills labs, and on-going CEU’s.
  • Updates management regarding potential problems or concerns.  Also responsible for consulting with clinicians or managers as needed.
  • Maintains an understanding of the company’s scope of services.
  • Understands the infrastructure and how and where to transfer calls in the company.  
  • Maintains a professional image.
  • Uses appropriate phone etiquette. Understands the infrastructure of Peoples Home Health to appropriately transfer calls within the agency
  • Promotes a customer friendly atmosphere for all visitors and ensures patient confidentiality at all times.
  • Participates in accreditation program.
  • Performs other duties as assigned.


  • Self-Starter – Takes initiative identifies needs of co-workers and customers and solves problems.
  • Reading Comprehension – Understanding written sentences and paragraphs in work related documents.
  • Time Management – Managing one’s own time
  • Speaking – Talking to others to convey information effectively.
  • Writing – Communicating effectively in writing as appropriate for the needs of the audience.
  • Critical Thinking – using logic and reasoning to identify the strengths ands weaknesses of alternative solutions, conclusions, or approaches to problems.
  • Able to perform the essential functions of the job with or without accommodation.



Graduate of an accredited RN program required. Geriatric care and/or adult cardiac nursing practice with home care experience preferred.  Skills required to work independently while providing high quality, timely communication to internal and external customers.

Licenses, Certifications and/or Registrations:

Current RN license in the State of Florida.  Current CPR certification.  Current driver’s license and valid auto insurance. Completion of 25 CEU’s bi-annually. 


Working Conditions:

Office/Home Environment. May be exposed to biological hazards.  

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