Primary Care Transition Of Care Nurse

Greater Seacoast Community Health | Somersworth NH
Full-Time | Day Shift | Non-Exempt | Essential Role
Department:
Quality & Population Health

• LPN: $31.00 – $37.00/hr (Based on experience)
• RN: $36.00 – $44.00/hr (Based on experience)

Care doesn’t stop when a patient leaves the hospital — and neither do we.

At Greater Seacoast Community Health (GSCH), our Transitions of Care Nurses are the vital link that ensures patients move safely, confidently, and successfully from hospitals or skilled nursing facilities back into primary care.

If you’re a nurse who thrives on coordination, patient education, and preventing avoidable readmissions — this role puts your clinical judgment, compassion, and organization to work where it matters most.

Reduce hospital readmissions and emergency department visits

Improve patient outcomes through proactive follow-up and education

Strengthen continuity of care across settings

Build meaningful relationships with patients and families during critical transitions

You’ll collaborate closely with providers, hospitals, care managers, specialists, and community partners — all while helping patients feel supported, informed, and empowered.

Identify and track patients recently discharged from hospitals, EDs, or post-acute facilities

Conduct timely post-discharge outreach to assess patient status and needs

Perform medication reconciliation and identify barriers to adherence

Ensure discharge instructions are understood and follow-up appointments are completed

Assess for red flags, worsening symptoms, or unmet clinical needs

Provide education on diagnoses, medications, self-management, and warning signs

Escalate concerns appropriately to primary care providers and care teams

Support coverage for primary care nursing needs as required

Coordinate care with hospitals, specialists, home health agencies, and community resources

Communicate clearly and consistently with primary care providers

Participate in interdisciplinary care team meetings and quality improvement efforts

Accurately document patient interactions and care plans in the EHR

Track outcomes such as readmissions, ED utilization, and patient engagement

Support value-based care initiatives and transitions-of-care regulatory requirements

Registered Nurse (RN) or Licensed Practical Nurse (LPN)

1–3 years of experience in clinical practice, care management, population health, or transitional care

Strong assessment, communication, and care coordination skills

Ability to work independently while collaborating across teams

Comfort with electronic health records and data tracking

A patient-centered, calm, and solution-oriented approach

We support our team members with a culture of trust, teamwork, and continuous improvement — because when our staff are supported, our patients thrive.

GSCH is a nonprofit network of community health centers serving New Hampshire’s Seacoast region. We provide integrated medical, dental, behavioral health, recovery, and social services — caring for the whole person, at every stage of life.

If you’re a nurse who wants to improve outcomes, prevent readmissions, and play a critical role in coordinated care — we’d love to hear from you.

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Apply today and help guide patients through safer, stronger transitions of care.

Greater Seacoast Community Health is an Equal Opportunity Employer.