Care Transition Nurse

Care Transition Nurse (RN)

The Care Transition Nurse (RN) coordinates and manages patient care transitions across healthcare settings, including hospital discharge to home, rehabilitation, or skilled nursing facilities. The role focuses on improving continuity of care, reducing hospital readmissions, and ensuring patients and caregivers understand discharge instructions, medications, and follow-up care plans.

Key Responsibilities

• Coordinate safe patient transitions from hospital to home or post-acute care facilities.
• Conduct comprehensive patient assessments prior to discharge.
• Provide education to patients and caregivers on disease management, medications, and care plans.
• Perform medication reconciliation to ensure accuracy and patient understanding.
• Schedule and confirm follow-up appointments with primary care providers or specialists.
• Collaborate with physicians, social workers, case managers, and community providers, with a focus on identifying Starling patients.
• Identify high-risk patients and implement interventions to prevent readmissions.
• Coordinate home health services, medical equipment, and community resources, ensuring the best care with consultants.
• Conduct post-discharge follow-up calls or visits to monitor patient progress.
• Maintain accurate documentation in the electronic medical record (EMR).
• Ensure compliance with Medicare, Medicaid, and Connecticut healthcare regulations.

Qualifications

Required

• Active Registered Nurse (RN) license in Connecticut
• Associate or Bachelor's degree in Nursing
• 3+ years clinical nursing experience (hospital, case management, discharge planning, or care coordination)

Preferred

• BSN
• Certification such as Certified Case Manager (CCM) or Accredited Case Manager (ACM)
• Experience with population health or value-based care programs

Key Skills

• Care coordination
• Patient and family education
• Clinical assessment
• Discharge planning
• Interdisciplinary collaboration
• Documentation and compliance