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Registered Nurse Transitions-of-Care Coordinator

PortlandOn-siteFull-time

AI Summary

Coordinates transitions-of-care for pulmonary patients, ensuring follow-up, communication, and seamless management of complex respiratory care.

About this role

Chest Medicine Associates

Registered Nurse Transitions-of-Care Coordinator

South Portland, Maine

Chest Medicine Associates is seeking a full-time Registered Nurse to serve as the RN Transitions-of-Care Coordinator-Pulmonary Medicine to serve as a central resource for patients, families, physicians, and hospital teams, ensuring timely follow-up, seamless communication, and coordination of complex pulmonary care.

This is a full-time, Monday–Friday daytime position with no routine evening, weekend, or holiday responsibilities. This position will be grant-supported for two years and may be contingent on renewal of grant funding.

Requirements:

  • Registered Nurse with an active, unrestricted Maine license.

  • Bachelor of Science in Nursing (BSN).

  • Current American Heart Association Basic Life Support (BLS) certification.

  • Minimum of two years of clinical nursing experience.

  • Strong clinical assessment and telephone triage skills.

  • Excellent communication and interpersonal skills.

  • Proficiency with electronic health record systems and Microsoft Office applications

  • Experience in pulmonary medicine, hospital medicine, case management, care coordination, and/or transitions of care is preferred

  • Experience caring for patients with COPD, ILD, asthma, bronchiectasis, or other chronic respiratory diseases is preferred.

  • Familiarity with pulmonary rehabilitation, home oxygen therapy, durable medical equipment, and insurance authorization processesis preferred.

Benefits of the Job:

  • Hourly pay in the range of $40-46 depending on experience and qualifications.

  • Health, Dental, Vision Insurance

  • 401K with match

  • PTO and paid holidays

  • Profit sharing

  • Paid parental leave

  • Tuition reimbursement

  • Convenient location in South Portland, Maine

Responsibilities:

  • Identify hospitalized pulmonary patients appropriate for transitions-of-care services, with emphasis on COPD and ILD.

  • Collaborate with inpatient teams, case management, respiratory therapy, pharmacy, and primary care providers and coordinate timely pulmonary follow-up appointments and diagnostic testing.

  • Contact patients within 24–72 hours of discharge to assess recovery, reinforce discharge instructions, and identify barriers to care.

  • Perform medication reconciliation and reinforce inhaler technique and medication adherence.

  • Assess oxygen, nebulizer, CPAP/BPAP, and other durable medical equipment needs.

  • Facilitate referrals to pulmonary rehabilitation, smoking cessation, home health, palliative care, and community resources.

  • Monitor for clinical deterioration and collaborate with providers to facilitate intervention.

  • Coordinate referrals for EBUS and robotic bronchoscopy.

  • Schedule procedures and required pre-procedure testing.

  • Ensure required imaging and diagnostic studies are available.

  • Track patients from referral through pathology results and treatment planning.

  • Coordinate post-procedure follow-up and collaborate with the lung cancer screening program to facilitatetimely evaluation of abnormal screening findings.

  • Perform pulse oximetry testing, nebulizer treatments, medication administration, and other nursing procedures within scope of practice.

Skills

BLSCPAPElectronic Health RecordsMicrosoft OfficeNebulizerPulmonary RehabilitationTelephone TriageVentilator

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