Job Details:
Job Summary
The Acute Care Nurse Transition Coordinator (NTC) manages the transition of high-risk patients from hospital to home by implementing targeted transition-of-care interventions. The role focuses on reducing preventable readmissions, improving patient outcomes, and ensuring safe, coordinated care.
Essential Responsibilities and Duties
Clinical Coordination & Navigation
- Identify inpatients at high risk for readmission using the electronic health record (EHR) and other risk stratification tools.
- Coordinate patient care during the inpatient stay, collaborating with the interdisciplinary team to support safe and timely discharge.
- Serve as a liaison between patients, families, and care providers including primary care, specialists, home care agencies, and skilled nursing facilities.
- Assess psychosocial, socioeconomic, and clinical barriers to care and supports development of individualized discharge plans.
- Coordinates post-acute care needs with post-discharge care teams (Transition of Care team and Catholic Health Home Care)
Patient Education & Advocacy
- Assists patients in understanding their diagnosis, treatment options, and resources in a manner that is culturally and linguistically appropriate and respects patients’ care preferences.
- Identifies co-learners (family members/caregivers) as appropriate and provides educational materials and referrals for health maintenance.
- Educates patients and co-learners on signs and symptoms of exacerbation or relapse. Communicates the critical importance of compliance with diet and medication regimens.
- Face to face interactions with patients and families is necessary
Quality Improvement & Strategic Collaboration
- Contribute to the development and refinement of transition-of-care education tools and workflows.
- Collaborate with clinical, quality, and care management teams to monitor outcomes and support readmission reduction strategies.
- Maintain knowledge of CMS Hospital Readmission Reduction Program requirements and ensure interventions align with regulatory standards.
- Monitor and report trends in unplanned hospital returns and support data collection for facility and system reporting.
- Meets weekly with TOC and Home Care to insure post discharge plans of care is followed
- Participates in person at unit/hospital huddles/multidisciplinary meetings to support care coordination and process improvement initiatives.
Qualifications & Requirements
- Education: BSN from an accredited school of nursing (required)
- Licensure: Active NYS RN license
- Experience: 3–5 years of acute care nursing experience (Med/Surg, Critical Care, or Telemetry)
Skills & Competencies
- Strong clinical judgment and ability to prioritize high-risk patients in a self-directed role
- Effective written and verbal communication skills
- Proficiency with EHR systems (Epic, Cerner preferred)
- Working knowledge of Microsoft Office for reporting and presentations
- Demonstrates excellent written and verbal communication skills, with the ability to convey complex clinical information clearly and concisely to patients, families, and interdisciplinary team members.
Physical Requirements
- Mobility: Ability to stand, sit, and walk in the nursing units to interview patients and families. Occasional stooping, kneeling, crouching, and reaching may be required to assist patients.
Posted Salary Range:
USD $65.20 - USD $78.24 /Hr.