Registered Nurse (RN) - Care Transitions Coordinator - Full Time Days (Onsite)

Holy Name Medical Center; Teaneck Township (NJ); On-site; USD 94,000 - 109,000; Full time

Benefits offered by this job

401(k) matching

Tuition reimbursement

Paid time off

Flexible spending accounts

Life insurance

Free on-site parking

Job summary

Holy Name Medical Center in Teaneck, NJ is seeking a RN Care Transitions Coordinator to lead discharge planning and post-acute care coordination. The role focuses on safe, cost-effective care and reduced length of stay through interdisciplinary collaboration.

Responsibilities include plan modifications, communications with payors, and arranging home care referrals, transportation, and post-discharge support while ensuring regulatory compliance.

Qualifications

• 4-6 years of acute care experience required
• Disease management and discharge planning experience preferred
• Analytical and problem-solving abilities with strong verbal and written communication skills

Responsibilities

• Modification of plan of care to meet ongoing patient needs
• Communicate information to third party payors and care team
• Complete required documentation in patient records
• Issues Notices of Non-Coverage per hospital policy
• Refer appropriate cases for social work intervention
• Knowlegeable about Indigent Medication Programs
• Verify patient demographics and insurance information
• Expedites execution of plan of care for patients in Observation units
• Arrange transportation for discharged patients
• Ensure compliance with regulatory standards for Observation patients (CMS Code 44)
• Use Patient Choice list for post-discharge support and document
• Initiate home care referrals and arrange ambulance transportation as needed
• Participate in discharge rounds and advocate for patient in discharge planning
• Attend family meetings as indicated
• Other duties as assigned

Skills

Analytical thinking

Communication skills

Education

Bachelor's Degree BSN Preferred

Job description

Description

RN, Care Transitions Coordinator

Welcome to Holy Name, a medical center where innovation is not just a goal — it's a commitment. Here, medical excellence thrives, allowing hope to reign supreme and leaving no room for fear. At our hospital, every patient is cared for with undivided attention — because healing every soul is our sole focus.

Holy Name is New Jersey's only independent Catholic health system, comprising a 361‑bed acute care hospital, a renowned cancer center, a state‑of‑the‑art fitness center, a residential hospice, a prestigious nursing school, and an extensive physician network. Healing at Holy Name goes beyond medicine and technology – it is infused with faith, conviction, compassion, and a commitment to educating the next generation of healthcare professionals through a variety of residency and educational programs. Our mission to provide care for the body, mind, and soul spans education, prevention, diagnosis, treatment, rehabilitation, and overall wellness. This is at the core of who we are and what we do, and we've done it this way across generations, every single day, for nearly 100 years. Every innovation, medical breakthrough, and groundbreaking treatment is powered by some of the best minds in medicine, ensuring nothing is left on the table or the road to recovery.

Brief Overview

The Care Transitions Coordinator is responsible for facilitating and coordinating services for patients through the continuum of care. The Care Transitions Coordinator ensures appropriate utilization of resources and safe delivery of care to all patients and provides quality and cost‑effective care that will lower Length of Stay (LOS) and decrease the fragmentation of services that can potentially compromise patient care. Care Transitions Coordinator collaborates efforts as a team in order to perform one or more of the following roles: Discharge Planning and Disease Management of acute and chronic conditions, facility placement needs as needed and timely referrals and evaluations of all post‑acute care needs. The Care Transitions Coordinator play a pivotal role for patients as part of the interdisciplinary team in order to ensure patient safety, quality of care and positive patient outcomes. Rotation of coverage for weekends and holidays will be required and are assigned throughout the year.

What You Will Do

• Modification of plan of care, as necessary, to meet the ongoing needs of the patient
• Communicate relevant information to third party payors and the care team.
• Completion of all required documentation in patient records
• Issues Notices of Non‑Coverage per hospital policy.
• Refers appropriate cases for social work intervention based on department criteria
• Knowledgeable about Indigent Medication Programs
• Verifies patient demographics and insurance information is correct
• Expedites execution of plan of care for patients in Observation units.
• Arranges transportation for patients slated for discharge.
• Uphold compliance of regulatory standards for Observation patients including CMS requirement for Code 44.
• Utilizes “Patient Choice” list for support services post discharge and documents.
• Initiates home care referrals for VNS, orders durable medical equipment and arranges ambulance transportation as needed for patients prior to discharge or transfer to another facility.
• Participates as an active, informative and cooperative team member of the health care staff by attending discharge rounds for case finding/follow up and participating in the discharge plan while acting as an advocate for the patient. Arranges family meetings to assist in discharge planning as indicated
• Other duties as assigned

Education Qualifications

• Bachelor's Degree BSN Preferred or

Experience Qualifications

• 4-6 years 3-5 years experience in an acute care setting Required and
• Disease Management and Discharge planning experience Preferred

Knowledge, Skills, And Abilities

• Analytical and problem solving along with excellent verbal and written communication skills.

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure Upon Hire Required and
• CCM - Certified Case Manager Upon Hire Preferred

At Holy Name, we believe in rewarding every team member with more than a paycheck—we invest in your future and well-being. Full‑time and part‑time employees have access to a comprehensive benefits package designed to support your health, financial security, and quality of life. We offer low‑cost medical coverage with generous employer contributions, dental and vision plans, discounted prescriptions, and access to on‑site child care. Additional benefits include 401(k) matching, tuition reimbursement, paid time off, flexible spending accounts, legal and voluntary coverage options, life insurance, and free on‑site parking. If you are hired at Holy Name, your final base compensation will be determined based on factors such as employment status (Full/Part‑Time or Per Diem) skills, education, and/or experience. In addition to those factors – we believe in the importance of pay equity and consider any internal equity of our current team members as a part of any final offer. Pay Range: $93,600.00 - $109,200.00

Holy Name is a mission‑driven facility whose quality standards and philosophy are rooted in the principles of its founders, the Sisters of St. Joseph of Peace. Those principles are exercised daily by the Medical Center's dedicated and talented staff members. Holy Name is an Equal Opportunity Employer.