Registered Nurse Transitions-of-Care Coordinator

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 processes is 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 facilitate timely evaluation of abnormal screening findings. 

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