Transitional Care RN: Post-Discharge Care Navigator

Oneida-Healthcare; City of Utica (NY); On-site; USD 75,000 - 95,000; Full time

Job summary

Oneida-Healthcare is seeking a Transitional Care Management (TCM) RN to support patients moving from inpatient stays to home care, coordinating with PCPs and outpatient teams. The RN will review discharge plans, document in Medent, and ensure timely follow-up after discharge.

The role emphasizes discharge planning, patient communication, and care coordination within New York state guidelines, with routine follow-up for 30 days as directed by the PCP.

Qualifications

• Current NY RN license is required.
• 2 years of nursing experience.
• Experience in medical office environment is a plus.

Responsibilities

• Identify eligible patients for TCM services and contact them within 2 business days.
• Schedule TCM visit with PCP within 7–14 days of discharge.
• Document all patient interactions in the Medent record.

Skills

Care coordination

Patient communication

Discharge planning

Medent documentation

Education

Associate degree in nursing

Bachelor of Science in Nursing

Tools

Medent EHR

RHIO access

Job description

Oneida-Healthcare is seeking a Transitional Care Management (TCM) RN to support patients moving from inpatient stays to home care, coordinating with PCPs and outpatient teams. The RN will review discharge plans, document in Medent, and ensure timely follow-up after discharge.

The role emphasizes discharge planning, patient communication, and care coordination within New York state guidelines, with routine follow-up for 30 days as directed by the PCP.