Care Transition RN: Discharge Coordination

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

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.