Care Transition Nurse: Discharge, Education & Coordination

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

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