Transition of Care Nurse

Overview

The Transitions of Care (TOC) Nurse provides timely, telephonic clinical outreach to family members following acute care, skilled nursing, or facility-based discharges to support safe and effective transitions across care settings. This role focuses on reducing avoidable readmissions, closing quality care gaps, and improving patient outcomes through assessment, education, care coordination, and escalation as needed. The TOC Nurse serves as a critical clinical touchpoint during high‑risk transition periods and collaborates closely with interdisciplinary teams to ensure continuity of care.

This role supports value‑based care objectives by improving utilization outcomes and quality performance.

• Conduct timely post‑discharge telephonic outreach in accordance with established TOC workflows and timelines.
• Perform comprehensive clinical assessments to identify post‑discharge risks, unmet needs, and barriers to recovery.
• Complete medication reconciliation, reinforce discharge instructions, and assess understanding of care plans.
• Educate family members on symptom monitoring, red flags, follow‑up care, and self‑management strategies.
• Coordinate follow‑up appointments with primary care providers, specialists, and ancillary services as appropriate.

• Monitor emergency department, skilled nursing facility, and hospital admission feeds to identify transitions of care opportunities and initiate timely outreach.
• Support effective transitions of care through coordination with hospitals, SNFs, caregivers, and care teams.
• Track care plan interventions and outcomes and reassess Family Member needs on an ongoing basis.
• Identify long length of stay admissions in hospital, LTAC, and SNF and schedule escalation to the clinical team as needed.

• Identify and escalating clinical concerns, care gaps, or social barriers to appropriate care team members.
• Collaborate with primary care practices, care managers, pharmacists, social workers, and other partners to ensure continuity of care.
• Facilitate referrals to community‑based resources or internal programs to address identified needs.
• Document and communicate actionable information to support timely intervention and risk mitigation.

• Support closure of quality gaps related to transitions of care, medication adherence, and follow‑up.
• Contribute to reduction of hospital readmissions, emergency department utilization, and total cost of care.
• Adhere to evidence‑based TOC models and organizational protocols aligned with value‑based care programs, including ACO and MSSP requirements.
• Participate in quality improvement initiatives and feedback loops to enhance TOC effectiveness.

• Accurately document all outreach, assessments, interventions, and outcomes in designated EHRs or care management platforms.
• Ensure timely, complete, and compliant documentation to support reporting, audits, and performance monitoring.
• Communicate key findings and trends to leadership and interdisciplinary teams as required.

• Maintain active RN licensure and adhere to professional nursing standards and scope of practice.
• Participate in onboarding, training, and ongoing education related to transitions of care and value‑based care models.
• Support a culture of patient‑centered, high‑quality, and accountable care delivery.

Active Compact Registered Nurse (RN) license in good standing required; ability and willingness to obtain multi‑state licensure as needed. Nurse Licensure Compact (NLC) license preferred; applicant will be required to apply for additional state licensure.

Bachelor of Science in Nursing (BSN) required.

• Clinical nursing experience required; experience in care management, transitions of care, case management, or population health preferred.
• Experience providing telephonic or remote patient support preferred.
• Familiarity with post‑acute care settings, discharge planning, or care coordination strongly preferred.

• Strong clinical assessment and critical thinking skills.
• E…