Nurse Transition Coordinator

Job Summary

The Acute Care Nurse Transition Coordinator (NTC) manages the transition of high-risk patients from hospital to home by implementing targeted transition-of-care interventions. The role focuses on reducing preventable readmissions, improving patient outcomes, and ensuring safe, coordinated care.

• Identify inpatients at high risk for readmission using the electronic health record (EHR) and other risk stratification tools.
• Coordinate patient care during the inpatient stay, collaborating with the interdisciplinary team to support safe and timely discharge.
• Serve as a liaison between patients, families, and care providers including primary care, specialists, home care agencies, and skilled nursing facilities.
• Assess psychosocial, socioeconomic, and clinical barriers to care and supports development of individualized discharge plans.
• Coordinates post-acute care needs with post-discharge care teams (Transition of Care team and Catholic Health Home Care).
• Assists patients in understanding their diagnosis, treatment options, and resources in a manner that is culturally and linguistically appropriate and respects patients’ care preferences.
• Identifies co-learners (family members/caregivers) as appropriate and provides educational materials and referrals for health maintenance.
• Educates patients and co‑learners on signs and symptoms of exacerbation or relapse. Communicates the critical importance of compliance with diet and medication regimens.
• Face to face interactions with patients and families is necessary.

The Acute Care Nurse Transition Coordinator (NTC) manages the transition of high-risk patients from hospital to home by implementing targeted transition-of-care interventions. The role focuses on reducing preventable readmissions, improving patient outcomes, and ensuring safe, coordinated care.

• Identify inpatients at high risk for readmission using the electronic health record (EHR) and other risk stratification tools.
• Coordinate patient care during the inpatient stay, collaborating with the interdisciplinary team to support safe and timely discharge.
• Serve as a liaison between patients, families, and care providers including primary care, specialists, home care agencies, and skilled nursing facilities.
• Assess psychosocial, socioeconomic, and clinical barriers to care and supports development of individualized discharge plans.
• Coordinates post-acute care needs with post-discharge care teams (Transition of Care team and Catholic Health Home Care).

• Assists patients in understanding their diagnosis, treatment options, and resources in a manner that is culturally and linguistically appropriate and respects patients’ care preferences.
• Identifies co-learners (family members/caregivers) as appropriate and provides educational materials and referrals for health maintenance.
• Educates patients and co‑learners on signs and symptoms of exacerbation or relapse. Communicates the critical importance of compliance with diet and medication regimens.
• Face to face interactions with patients and families is necessary.

• Contribute to the development and refinement of transition‑of‑care education tools and workflows.
• Collaborate with clinical, quality, and care management teams to monitor outcomes and support readmission reduction strategies.
• Maintain knowledge of CMS Hospital Readmission Reduction Program requirements and ensure interventions align with regulatory standards.
• Monitor and report trends in unplanned hospital returns and support data collection for facility and system reporting.
• Meets weekly with TOC and Home Care to insure post discharge plans of care is followed.
• Participates in person at unit/hospital huddles/multidisciplinary meetings to support care coordination and process improvement initiatives.

• Education:
  
  BSN from an accredited school of nursing (required)
• Licensure:
  Active NYS RN license
• Experience:
  
  3–5 years of acute care nursing experience (Med/Surg, Critical Care, or Telemetry)

• Strong clinical judgment and ability to prioritize high-risk patients in a self-directed role
• Effective written and verbal communication skills
• Proficiency with EHR systems (Epic, Cerner preferred)
• Working knowledge of Microsoft Office for reporting and presentations
• Demonstrates excellent written and verbal communication skills, with the ability to convey complex clinical information clearly and concisely to patients, families, and interdisciplinary team members.

• Mobility:
  Ability to stand, sit, and walk in the nursing units to interview patients and families. Occasional stooping, kneeling, crouching, and reaching may be required to assist patients.

USD $65.20 - USD $78.24 /Hr.