Remote RN - Transitions of Care
Benefits
- Paid Time Off & Paid Company Holidays
- Medical, Dental, Vision & Life Insurance
- Flexible Spending Account (FSA)
- 403(b) Retirement Plan with Company Match
- Short-Term & Long-Term Disability
- $0 Copay for Legacy Provider visits
- $0 Copay for prescriptions filled at Legacy Pharmacies
- Travel Insurance & Pet Insurance
- Subsidized Gym Membership
- And much more!
Apply today in less than 3 minutes using your phone, tablet, or computer!
Location: Legacy Montrose Allen Parkway - 2929 Allen Pkwy Ste 1300. Houston, TX 77019 (Hybrid) (Onsite - First 30 Days / Remote - After 30 Days)
RN - Transitions of Care (Job Overview)
Schedule: Monday-Friday (8AM-4PM)
Step into a revolutionary role where healthcare innovation meets community impact. Start strong with one month of onsite training to connect, collaborate, and get immersed in our culture. After that, enjoy remote work with one purposeful onsite meeting each month to stay aligned and inspired. As a Transitions of Care Registered Nurse (TOCRN) at Legacy Community Health, you will leverage cutting-edge methodologies to transform the way patients transition from inpatient settings to home care.
- Engage in telephonic outreach that revolutionizes patient reintegration with personalized assessments.
- Collaborate with Care Teams to drive down readmission rates with game-changing follow-up strategies.
- Embrace a technology-driven workflow to ensure seamless care coordination and documentation.
- Be at the forefront of digital transformation by integrating data-driven insights into patient care plans.
- Contribute to a mission-driven organization focused on pioneering advancements in community healthcare.
Join us where innovation in healthcare thrives and community impact knows no bounds.
Key Responsibilities
- Execute telephonic outreach within one business day to patients discharged from inpatient settings.
- Conduct comprehensive assessments to uncover and address unmet patient needs.
- Deliver cutting-edge education on discharge plans, medication management, and disease processes.
- Facilitate scheduling of follow-up care and deploy referrals for additional management seamlessly.
- Collaborate with multidisciplinary care teams to optimize clinical outcomes and ensure robust medical documentation.
- Adhere to safety reporting guidelines while participating in the co-creation of new work standards.
- Proactively manage caseloads to prevent unnecessary emergency room visits and hospital readmissions.
- Engage in continuous learning through regular meetings and educational offerings.
Minimum Qualifications
- Registered Nurse with active, unrestricted Texas licensure and State Board recognized nursing education.
- 3-5 years of acute clinical experience coupled with 1-2 years of case/care management expertise.
- Proficiency with diverse patient populations including Commercial, Medicaid, and Medicare.
- Exceptional computer literacy and customer service skills to enhance patient interactions.
- Desirable: Experience in Federally Qualified Health Clinics and bilingual proficiency in Spanish.
About Legacy Community Health
As the largest Federally Qualified Health Center (FQHC) in Southeast Texas, Legacy Community Health has been delivering comprehensive, high-quality, and affordable health care for nearly 40 years. With more than 50 clinics across the Greater Houston and Gulf Coast region, we continue to grow strategically and invest in our communities. By innovating how care is delivered, we've stayed at the forefront of connecting our communities to health—every day, in every way. At Legacy, we know our success is powered by our people. We're always looking for talented, passionate individuals who want more than a job—they want a meaningful career that makes a real impact. Explore our open positions and see if a career at Legacy is right for you.At Legacy Community Health, our mission—Driving healthy change in our communities—guides everything we do. To fulfill this mission, every team member is expected to embody the following core attributes in their daily work, regardless of role or department:
Approachable & Collaborative
We bring our expertise without ego. In a collaborative healthcare environment, humility fosters trust and teamwork. Our employees value diverse perspectives, seek input from others, and are unafraid to acknowledge when they need help. We stay grounded in our purpose: to serve patients and communities with compassion and humility.
Driven & Committed
We are driven by a deep commitment to excellence in patient care and organizational improvement. Our employees take initiative, embrace challenges, and go the extra mile to support our mission. Whether improving patient outcomes, streamlining processes, or stepping up in times of need, we are always striving to drive healthy change—within ourselves, our teams, and the communities we serve.
Perceptive & Thoughtful Communicators
We value emotional intelligence as much as clinical or technical skill. Our team members demonstrate sound judgment, cultural sensitivity, and the ability to navigate complex situations with empathy and professionalism. They communicate clearly and respectfully with patients, families, and colleagues, building trust and fostering a safe, inclusive environment for all.