Registered Nurse: Transitions of Care

About Synapticure

As a patient and caregiver-founded company, Synapticure provides instant access to expert neurologists, cutting-edge treatments and trials, and wraparound care coordination and behavioral health support in all 50 states through a virtual care platform. Partnering with providers and health plans, including CMS' new GUIDE dementia care model, Synapticure is dedicated to transforming the lives of millions of individuals and their families living with neurodegenerative diseases like Alzheimer’s, Parkinson’s, and ALS.

The Role

The Transitions of Care Nurse (TOC Nurse) plays a vital role in managing and coordinating patient care as they transition from hospitals or other healthcare settings back into the community. This position ensures that patients receive the necessary education, resources, and follow-up care to prevent readmissions, improve outcomes, and enhance overall patient satisfaction. The TOC Nurse collaborates with multiple stakeholders to ensure a seamless transition and may be required to take on-call duties on a rotating basis to provide support during evenings, weekends, or holidays

• Care Coordination: Collaborate with physicians, discharge planners, social workers, and primary care providers to ensure patients are prepared for safe and effective transitions from hospital to home or other healthcare settings.
• Comprehensive Assessments: Conduct assessments to identify medical, psychological, and social barriers to a successful transition and develop personalized care plans.
• Patient Education: Provide clear instructions regarding medications, treatments, follow-up appointments, and lifestyle changes. Educate patients and caregivers on recognizing warning signs that may require urgent care.
• Follow-Up Care: Schedule follow-up appointments with primary care providers, specialists, and other healthcare services. Conduct telehealth visits or phone follow-ups to monitor adherence to care plans and identify unmet needs.
• Patient Advocacy: Act as a liaison between patients, families, and healthcare providers to ensure effective communication and care delivery. Address questions and concerns regarding care plans or discharge instructions.
• Documentation & Reporting: Maintain accurate records of patient interactions, progress, and follow-up actions. Track patient outcomes, including readmission rates, and recommend process improvements where necessary.
• Collaboration with Multidisciplinary Team: Work closely with hospital staff, outpatient teams, case managers, and community service providers to ensure holistic and coordinated patient care. Participate in case reviews and team meetings to discuss complex cases.

• Bachelor of Science in Nursing (BSN) or an associate degree in nursing (ADN) from an accredited program.
• Active and unrestricted Registered Nurse (RN) license.
• Comfortable using technology to support patients remotely (telephone, text etiquette, virtual visit platforms, etc.).
• Strong verbal and written communication skills, organizational abilities, and interpersonal skills to work effectively in a diverse team.
• Experience using scheduling platforms to ensure accurate appointment management.
• Familiarity with electronic health record (EHR) systems and care facilitation platforms for documentation.
• Proficient in collecting and documenting clinical and demographic data in a timely manner.
• Strong problem-solving skills, with the ability to make decisions and collaborate with team members when needed.
• Ability to develop creative solutions to healthcare system challenges that impact patient care optimization.
• Growth-oriented mindset, willingness to think outside traditional responsibilities, and adaptability to fast-paced changes and shifting priorities.
• Ability to build cooperative relationships with patients, teammates, healthcare providers, and community service organizations.

• Experience in clinical care for patients with neurodegenerative diseases.
• Bilingual fluency in Spanish to support a diverse patient and caregiver population.

• Relentless focus on patients and caregivers. We are determined to provide an exceptional experience for every patient we have the privilege to serve, and we put our patients first in everything we do.
• Embody the spirit and humanity of those living with neurodegenerative disease. Inspired by our founders, families, and personal experiences, we recognize the seriousness of our patients’ circumstances and meet that challenge every day with empathy, compassion, kindness, joy, and most importantly – with hope.
• Seek to understand, and stay curious. We start by listening to one another, our partners, our patients, and their caregivers. We communicate with authenticity and humility, prioritizing honesty and directness while recognizing we always have something to learn.
• Embrace the opportunity. We are energized by the importance of our mission and bias toward action.
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Travel Expectations

This role is fully remote, with occasional travel to company headquarters in Chicago, IL, or other locations as required.