Job Description​

The Opportunity: 

Saint Luke’s Home Care & Hospice is seeking a full-time Transitional Care Home Health Registered Nurse to join our team. The Transitional Care Nurse TCN, under the direction of the Director of Operations, plays a key role in the collaboration and partnership between SLHS Home Care and two innovative programs at Saint Luke’s Health System.  As a part of this collaboration, the TCN will provide home visits for patients that are enrolled in the Primary Care at Home Program, partnering with the Population Health Management Team. This program provides support to patients that have not utilized their health benefits to establish and continue to see their Primary Care Physicians.  The TCN’s visit will provide assessment, evaluation, education, coaching and counseling to patients and their families as well as the facilitation of virtual visits with a healthcare provider periodically. 

The TCN is also a primary resource for providing RN level visits to the newest innovative SLHS program called Hospital In Your Home.  This program provides acute care in the home setting for a certain population and home visits may be performed by an ARNP, paramedics, TCN’s, Home Health nurses and therapists as appropriate.   

The TCN also a consultant to SLHS Home Care staff on home health patients that need focused visits on care coordination and transitional management.  These patients are high risk for rehospitalizations and have a need for focused care and education on barriers to successfully managing their chronic diseases.   The TCN will also study the Care Coordination Transitional Care Management curriculum that consists of advocacy, education and engagement of individuals and families, coaching and counseling of individuals and families, person-centered care planning, support for self-management, nursing process, teamwork and collaboration, cross setting communications and care transitions, population health management, informatics to support nursing practice, telehealth nursing practice. Within two years, the TCN will obtain certification in a relevant program. 

The TCN will periodically monitor telehealth patients on home health. 

The Work: 

As a TCN, you will perform the following functions:  

• Disease management 
• Monitoring of telehealth patients as appropriate. 

• Utilize the nursing process throughout the provision of patient/family care. 
• Collaborate with the medical staff and the other disciplines to provide and enhance patient care 
• Adhere to all nursing policies and standards, and proactively strive to maintain and improve quality outcomes 

Why Saint Luke’s Home Care and Hospice? 

• Our leadership supports nurse engagement and allows their voices to be heard.  
• We value our nurses’ knowledge, experience, and expertise to improve patient outcomes and quality care.  
• The opportunity to balance all facets of your life through flexible and creative scheduling that meet your          needs as well as your patients. 
• Strong nurse governance and we encourage all of our RNs to participate  

• Various CEU, Continuing Education, Leadership and other career training available 
• Career Advancement Program dedicated to RNs. 
• Saint Luke’s offers competitive salaries and benefits packages to all eligible employees, click here to find out more. 

Job Requirements

Applicable Experience:

Job Details

The best place to get care. The best place to give care. Saint Luke’s 12,000 employees strive toward that vision every day. Our employees are proud to work for the only faith-based, nonprofit, locally owned health system in Kansas City. Joining Saint Luke’s means joining a team of exceptional professionals who strive for excellence in patient care. Do the best work of your career within a highly diverse and inclusive workspace where all voices matter.

Join the Kansas City region's premiere provider of health services. Equal Opportunity Employer.

Effective November 1st, 2021, full COVID-19 vaccination is a condition of employment for all Saint Luke’s Health System employees unless a medical or religious exemption is approved.