Sutter Health Care Transitions Coordinator RN - Full Time Days in Oakland, California


Under the supervision of the East Bay Care Transitions Team Program Supervisor, the Care Transitions Coordinator RN functions within the Sutter Health East Bay to assure patients with diagnoses of: Acute Myocardial Infarction (AMI), Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Pneumonia (PNA), Sepsis, Complex Care Referrals and Preferred Post-Acute Care Partner Patients receive care and telephonic support that consistently follows evidence-based standards. Nurses in the program provide "care" and "support" for patients via telephone only; they do not make home visits or see/touch patients. The Care Transitions Coordinator RN uses care transitions and case management interventions to assess, intervene, educate and, actively plan care with the patient; the RN will also collaborate with other care providers (both in hospital and in the community) to ensure quality outcomes for their patients.


Education, Certifications, Licensure:

  • Registered Nurse - State Licensure - RN required

  • Bachelors in nursing or related field or equivalent education/experience preferred


  • Prior experience in cardiac nursing as demonstrated by a minimum of 3-5 years acute care experience or like experience in an outpatient setting required

  • Telemanagement or telemonitoring and/or disease management experience strongly preferred preferred

  • Heart Failure or Cardiovascular experience strongly preferred

  • Home Health, Case Management, and/or case management experience helpful preferred

Skills and Knowledge

  • Knowledge of chronic disease management, and educating and coaching patients to self manage their disease process.

  • Knowledge of health care and community resources appropriate for populations served.

  • Knowledge of individual and family development over the life span and, the influence of cultural and spiritual values in health care.

  • Knowledge of adult education and teaching principles.

  • Demonstrated computer proficiency with databases and Microsoft suite applications is required.

  • Ability to work collaboratively as a member of a multi-disciplinary healthcare delivery team across the continuum. Able to form harmonious working relationships with internal and external customers. Must have the ability to work in a high volume caseload environment and deal effectively with rapidly changing priorities.

  • Self-starter with a high degree of initiative, motivation, flexibility, energy and creativity. Must have the abilities to work both independently and within the healthcare team with a minimum of direction. Anticipates and proactively manages and organizes workflow. Strong ability to prioritize, plan, problem solve and, follow through with patients, team members and other health care providers.

  • Excellent communication skills. Must have excellent oral and written communication, organizational skills, interpersonal, problem-solving, time management, and positive personal influence and negotiation skills. Ability to work with a wide range of staff, including physicians, clinical staff, peers and senior management. . Excellent collaborative and problem solving skills with patients, families, caregivers, and other health care providers.

  • Must have strong clinical assessment, physical, psychosocial, and environmental, and critical thinking skills necessary to provide care-planning, treatment initiation and, follow-up based on algorithms appropriate to patients with complex medical, emotional, and social needs. Ability to take evidenced-based guidelines and translate to practice. Ability to motivate, mentor, coach, and redirect patients in order to achieve compliance with medical, social, and functional interventions.

  • Must be proactive and motivated with a high customer service orientation and a solutions-oriented approach.

  • Ability to work respectfully and creatively with clients of diverse functional abilities, social, economic, and cultural backgrounds to support both client autonomy and client safety.

  • Demonstrated leadership and negotiation skills and the ability to manage resources for patient care in a cost effective manner.

  • With appropriate training, demonstrates an ability to competently work with the computerized documentation tools and systems of the organization.

  • Ability to integrate within existing healthcare team and to work collaboratively across settings.

  • Telephone contact providing care to the patient, family/caregiver in the ambulatory setting with a detailed physical, psychosocial and environmental assessment.

  • Administers treatment plans based on evidence-based protocols and algorithms based on assessment of patient status and needs.

  • Communicates with PCP, Specialists and, community providers based upon established protocols and as needed.

  • Refers patients, families and caregivers to appropriate community resources.

  • Able to be part of a team across the continuum collaborating with other members to ensure the delivery of high quality of patient care.

  • Must be able to apply risk assessments, standardized procedures and protocols to patient populations.

  • Must be able to work with patient, family, caregiver, physicians, and other health care providers to plan the care of the patient short and long term.

  • Must have good organizational skills to ensure that all care needs related to the patient and daily job duties are completed in a timely and efficient manner.

  • Must be able to enter documentation into agency provided computerized documentation tools.

  • Must be able to handle sensitive issues, conflict with or among others.

  • Maintain a positive and professional image and demonstrate self-directed learning to meet professional development and/or license requirements.

  • Is responsible for maintaining all required licensure and certifications.

  • At orientation and annually thereafter, must be able to meet Regional core competencies for position and area of specialty, as appropriate.

Primary Location: California, East Bay, Oakland

Organization: Alta Bates Summit Medical Center

Employee Status: Regular

Employee Referral Bonus: No

Benefits: Yes

Position Status: Non-Exempt

Union: No

Job Shift: Day

Shift Hours: 8 Hour Shift

Days of the Week Scheduled: Monday-Friday

Weekend Requirements: Other

Schedule: Full Time

Hrs Per 2wk Pay Period: 80

All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, marital status, sexual orientation, registered domestic partner status, sex, gender, gender identity or expression, ancestry, national origin (including possession of a driver's license issued to individuals who did not present proof of authorized presence in the U.S.), age, medical condition, physical or mental disability, military or protected veteran status, political affiliation, pregnancy or perceived pregnancy, childbirth, breastfeeding or related medical condition, genetic information or any other characteristic made unlawful by local, state, or federal law, ordinance or regulation. External hires must pass a background check/drug screening. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state, and local laws, including but not limited to the San Francisco Fair Chance Ordinance.