Care Transition Nurse

shm; Hartford (CT); On-site; USD 75,000 - 95,000; Full time

Job summary

VillageMD is seeking a Care Transition Nurse (RN) to coordinate patient care across settings, focusing on safe hospital discharges and preventing readmissions. This role targets Connecticut residents and involves working with a multidisciplinary team to ensure clear discharge instructions and follow-up plans.

The ideal candidate will have an active CT RN license, an ASN or BSN, and at least three years of clinical nursing experience in hospital, discharge planning, or care coordination.

Qualifications

• Active Registered Nurse (RN) license in Connecticut.
• Associate or Bachelor's degree in Nursing.
• 3+ years of clinical nursing experience in hospital, case management, discharge planning, or care coordination.

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, focusing on identifying Starling patients.
• Identify high-risk patients and implement interventions to prevent readmissions.
• Coordinate home health services, medical equipment, and community resources.
• Conduct post-discharge follow-up calls or visits to monitor patient progress.
• Maintain accurate documentation in the EMR and ensure regulatory compliance.

Skills

Care coordination

Patient education

Clinical assessment

Discharge planning

Documentation

Interdisciplinary collaboration

Education

ASN or BSN

Active CT RN license

Tools

EMR systems

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

#INDNurse

About Our Commitment

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.