Care Transitions Nurse (RN) - Sinai Hospital

Summary


JOB SUMMARY:

The Care Transitions Nurse will provide intensive case management to high-risk patients post discharge. The Care Transitions Nurse is directly involved in managing the multiple elements that comprise a person's successful transition from hospital to home. He/she will conduct home visits, provide health education, assist in the coordination of health care needs of all complex cases, and develop professional referral relationships to ensure patient needs are met.

RESPONSIBILITIES:

Provides assessment of and discharge planning to the adult and geriatric populations enrolled in the Transitions program. • Receives high risk referrals via handoff from the Patient Care Liaisons. • Takes the lead in ensuring the continuity and consistency of care extending beyond the inpatient setting. Serves as a liaison to acute care hospitals and post-acute care services to facilitate comprehensive discharge planning and follow up care. • Meets with patient/family in the hospital setting to initiate relationship, enroll patient in program, schedule home visit, and reinforce teaching. • Meets with patient in the home setting 24-48 hours of discharge from the hospital to assess any immediate needs or issues, reinforce discharge instructions, medication reconciliation, assess self-management skills, evaluate the home for safety, assess for the presence or absence of a support system, identify barriers to care, and ensure timely outpatient follow up. • Participates in data collection as directed. Develops effective working relationships with Physicians, Nursing, other ancillary departments, and referral sources. • Meets with patient in the home setting 24-48 hours of discharge from the hospital to assess any immediate needs or issues, reinforce discharge instructions, medication reconciliation, assess self-management skills, evaluate the home for safety.

REQUIREMENTS:

• Minimum of 1 year of hospital experience; 3+ years of experience preferred
• Current RN license in Maryland (compact license as applicable)
• Current BLS Certification from the American Heart Association
• ADN required; BSN or higher preferred

Additional Information

Who We Are:


LifeBridge Health is a dynamic, purpose-driven health system redefining care delivery across the mid-Atlantic and beyond, anchored by our mission to "improve the health of people in the communities we serve." Join us to advance health access, elevate patient experiences, and contribute to a system that values bold ideas and community-centered care.



What We Offer:


Impact: Join a team that values innovation and outcomes, delivering life-saving care to our youngest and most vulnerable patients.


Growth : Opportunities for professional development, including tuition reimbursement and developing foundational skills for neonatal critical care leadership and advanced certification.


Support: A culture of collaboration with resources like unit-based practice councils and advanced clinical education support - improving both workflow efficiency and patient outcomes and allowing you to work at the top of your license.


Benefits : Competitive compensation (additional compensation such as overtime, shift differentials, premium pay, and bonuses may apply depending on job), comprehensive health plans, free parking, and wellness programs.



Why LifeBridge Health?


With over 14,000 employees, 130 care locations, and two million annual patient encounters, we combine strategic growth, innovation, and deep community commitment to deliver exceptional care anchored by five leading centers in the Baltimore region: Sinai Hospital of Baltimore, Grace Medical Center, Northwest Hospital, Carroll Hospital, and Levindale Hebrew Geriatric Center and Hospital.


Our organization thrives on a culture of CARE BRAVELY-where compassion, courage, and urgency drive every decision, empowering teams to shape the future of healthcare.


LifeBridge Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex or sexual orientation and gender identity/expression. LifeBridge Health does not exclude people or treat them differently because of race, color, national origin, age, disability, sex or sexual orientation and gender identity/expression.