Transition of Care Innovation RN

Position Summary:

The Transition of Care Innovation RN leads and delivers a payer-agnostic, nurse-led transition of care program for eligible older adults discharged from participating rural hospitals. The RN partners with patients, caregivers, hospital teams, primary care practices, pharmacists, home care, and community organizations to support a safe transition from hospital to home and reduce avoidable emergency department use and 30-day rehospitalizations. The RN coaches patients and caregivers to build the knowledge, confidence, and skills needed to manage medications, maintain an accurate patient-centered health record, complete timely follow-up, and recognize and respond to clinical red flags.

Schedule: Monday - Friday, 8 AM to 430PM no weekend, no holiday, no on call 

Qualifications

• Education: Bachelor of Science in Nursing required.
• Experience: Minimum of 3-5 years of clinical nursing experience in home health, care management, acute care, geriatrics, population health, or a closely related setting. Experience with transitions of care, discharge planning, patient education, or quality improvement strongly preferred.
• Licensure: Current New York State Registered Professional Nurse license in good standing.

• Identifies and screens patients using current program eligibility criteria and introduces the voluntary transition coaching program to eligible patients and caregivers.

• Collaborates with hospital discharge teams to identify risks, confirm the transition plan, and address barriers before or promptly after discharge.

• Completes timely post-discharge outreach and follow-up throughout the 30-day transition period, including a nurse visit or phone encounter when required by program standards.

• Supports patients and caregivers with medication self-management, use of a patient-centered health record, timely follow-up care, and recognition of and response to clinical red flags.

• Performs medication reconciliation and coaching; identifies discrepancies, access or adherence concerns, and high-risk issues; and coordinates resolution with pharmacists and providers.

• Assesses patient and caregiver understanding, health-related social needs, and barriers to recovery; provides education using teach-back and connects patients with appropriate clinical and community resources.

• Coordinates warm handoffs among primary care, specialists, home care, pharmacy, and community providers and escalates urgent clinical concerns according to established protocols.

• Documents outreach, assessments, interventions, referrals, escalations, goals, and outcomes in designated systems and supports planned completion or handoff at the end of the program.

• Tracks program measures, including enrollment, timeliness, follow-up care, emergency department use, and 30-day readmissions, and participates in case review, performance improvement, grant reporting, and partner meetings.

• Maintains competency in evidence-based transitional and geriatric care and provides flexible coverage and travel based on program needs.

Salary: $73,652.80 - $103,854.40

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