Registered Nurse Transitions-of-Care Coordinator

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

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• Registered Nurse with an active, unrestricted Maine license.
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• Bachelor of Science in Nursing (BSN).
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• Current American Heart Association Basic Life Support (BLS) certification.
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• Minimum of two years of clinical nursing experience.
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• Strong clinical assessment and telephone triage skills.
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• Excellent communication and interpersonal skills.
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• Proficiency with electronic health record systems and Microsoft Office applications
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• Experience in pulmonary medicine, hospital medicine, case management, care coordination, and/ or transitions of care is preferred
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• Experience caring for patients with COPD, ILD, asthma, bronchiectasis, or other chronic respiratory diseases is preferred .
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• Familiarity with pulmonary rehabilitation, home oxygen therapy, durable medical equipment, and insurance authorization processes is preferred .

Benefits of the Job

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• Hourly pay in the range of $40-46 depending on experience and qualifications.
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Health, Dental, Vision Insurance

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• 401K with match
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• PTO and paid holidays
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• Profit sharing
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• Paid parental leave
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• Tuition reimbursement
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• Convenient location in South Portland, Maine

Responsibilities

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

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

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

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Perform medication reconciliation and reinforce inhaler technique and medication adherence.

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

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

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

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Coordinate referrals for EBUS and robotic bronchoscopy.

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Schedule procedures and required pre-procedure testing.

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Ensure required imaging and diagnostic studies are available.

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Track patients from referral through pathology results and treatment planning.

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

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