Care Transition Nurse

Summit Health Management; Hartford (CT); On-site; USD 85,000 - 100,000; Full time

Benefits offered by this job

Medical

Dental

Life insurance

Disability

Vision

401k

Job summary

VillageMD in Hartford seeks a Care Transition Nurse (RN) to coordinate patient transitions from hospital to home or post-acute care, focusing on reducing readmissions and ensuring patients and caregivers understand discharge instructions and follow-up plans. The ideal candidate holds CT RN licensure with an associate or bachelor's degree in nursing and 3+ years in discharge planning or care coordination.

You will educate patients, perform reconciliations, and collaborate across the care team to

Qualifications

• Active Registered Nurse license in Connecticut.
• 3+ years in hospital, case management, discharge planning, or care coordination.
• BSN or higher and population health/value-based care experience preferred.

Responsibilities

• Coordinate safe patient transitions from hospital to home or post-acute care.
• Conduct comprehensive assessments prior to discharge.
• Educate patients and caregivers on disease management, medications, and care plans.
• Perform medication reconciliation for accuracy and understanding.
• Schedule and confirm follow-up appointments with care providers.
• Collaborate with physicians, social workers, case managers and community providers.
• Identify high-risk patients and implement readmission-prevention interventions.
• Coordinate home health services, equipment and community resources.
• Conduct post-discharge follow-up calls or visits and document in EMR.
• Ensure compliance with Medicare, Medicaid, and CT regulations.

Skills

Care coordination

Patient and family education

Clinical assessment

Discharge planning

Interdisciplinary collaboration

Documentation and compliance

Education

Associate or Bachelor’s degree in Nursing

BSN Certification such as CCM or ACM

Job description

About Our Company

We’re a physician-led, patient-centric network committed to simplifying health care and bringing a more connected kind of care. Our primary, multispecialty, and urgent care providers serve millions of patients in traditional practices, patients’ homes and virtually through VillageMD and our operating companies Village Medical, Village Medical at Home, Summit Health, CityMD, and Starling Physicians. When you join our team, you become part of a compassionate community of people who work hard every day to make health care better for all. We are innovating value-based care and leveraging integrated applications, population insights and staffing expertise to ensure all patients have access to high-quality, connected care services that provide better outcomes at a reduced total cost of care.

Please Note: We will only contact candidates regarding your applications from one of the following domains: @summithealth.com, @citymd.net, @villagemd.com, @villagemedical.com, @westmedgroup.com, @starlingphysicians.com, or @bmctotalcare.com.

Job Description

Position Summary

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

About Our Commitment

We are innovating value-based care and leveraging integrated applications, population insights and staffing expertise to ensure all patients have access to high-quality, connected care services that provide better outcomes at a reduced total cost of care.

Total Rewards at VillageMD

Our team members are essential to our mission to reshape healthcare through the power of connection. VillageMD highly values the critical role that health and wellness play in the lives of our team members and their families. Participation in VillageMD’s benefit platform includes Medical, Dental, Life, Disability, Vision, FSA coverages and a 401k savings plan.

Equal Opportunity Employer

Our Company provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to, and does not discriminate on the basis of, race, color, religion, creed, gender/sex, sexual orientation, gender identity and expression (including transgender status), national origin, ancestry, citizenship status, age, disability, genetic information, marital status, pregnancy, military status, veteran status, or any other characteristic protected by applicable federal, state, and local laws.

We’re a physician-led, patient-centric network committed to simplifying health care and bringing a more connected kind of care. Our primary, multispecialty, and urgent care providers serve millions of patients in traditional practices, patients’ homes and virtually through VillageMD and our operating companies Village Medical, Village Medical at Home, Summit Health, CityMD and Starling Physicians. When you join our team, you become part of a compassionate community of people who work hard every day to make health care better for all. We are innovating value-based care and leveraging integrated applications, population insights and staffing expertise to ensure all patients have access to high-quality, connected care services that provide better outcomes at a reduced total cost of care. The work we do is changing the lives of our patients, our communities, and each other. Join us as we deliver the care we want to see in the world. Together, we can create better outcomes for all.