Transitional Care Registered Nurse

Azza HealthCare Agency; Kansas City (MO); On-site; USD 70,000 - 100,000; Full time

Job summary

Azza HealthCare Agency in the United States is seeking a Transitional Care Nurse to coordinate safe, patient-centered transitions from hospital to home or post-acute settings. The role focuses on discharge planning, risk assessment, medication reconciliation, and clear patient education.

You will collaborate with physicians, social workers, and the interdisciplinary team to ensure compassionate, high-quality care and smooth handoffs that reduce readmissions and support patients and families

Qualifications

• Experience in discharge planning and patient education.
• Proficiency in medication reconciliation.
• Strong communication with patients and families.

Responsibilities

• Lead discharge planning to support continuity of care.
• Assess patient and transition risks to prevent readmissions.
• Perform medication reconciliation and promote medication safety.
• Provide clear education to patients and families regarding care plans and next steps.
• Collaborate with physicians, social workers, and the interdisciplinary team.
• Ensure transitions reflect compassionate, excellent, and innovative care.

Skills

Clinical assessment

Risk stratification

Discharge planning

Medication reconciliation

Patient education

Interdisciplinary collaboration

Patient advocacy

Job description

Transitional Care Nurse coordinates safe, patient-centered transitions from the hospital to home or post-acute settings.

Key Responsibilities

• Lead discharge planning to support continuity of care
• Assess patient and transition risks to prevent avoidable readmissions
• Perform medication reconciliation and promote medication safety
• Provide clear education to patients and families regarding care plans and next steps
• Collaborate with physicians, social workers, and the interdisciplinary team
• Ensure transitions reflect compassionate, excellent, and innovative care

Qualifications & Skills

• Strong clinical assessment and risk stratification skills
• Expertise in discharge planning and patient education
• Proficiency in medication reconciliation
• Ability to work effectively within an interdisciplinary care team
• Patient-centered communication and advocacy