Care Transition Nurse
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Job Location:
Hartford, CT - USA
Monthly Salary:
Not Disclosed
Posted on:
2 days ago
Vacancies:
1 Vacancy
Job Summary
About Our Company
Were a physician-led patient-centric network committed to simplifying health care and bringing a more connected kind of care.
Our primary multispecialty and urgent care providers serve millions of patients in traditional practices patients homes and virtually through VillageMD and our operating companies Village Medical Village Medical at Home Summit Health CityMD and Starling Physicians.
When you join our team you become part of a compassionate community of people who work hard every day to make health care better for are innovating value-based care and leveraging integrated applications population insights and staffing expertise to ensure all patients have access to high-quality connected care services that provide better outcomes at a reduced total cost of care.
Please Note: We will only contact candidates regarding your applications from one of the following domains: @ @ @ @ @ @ or @.
Job Description
Position Summary
The Care Transition Nurse (RN) coordinates and manages patient care transitions across healthcare settings including hospital discharge to home rehabilitation or skilled nursing facilities. The role focuses on improving continuity of care reducing hospital readmissions and ensuring patients and caregivers understand discharge instructions medications and follow-up care plans.
Key Responsibilities
- Coordinate safe patient transitions from hospital to home or post-acute care facilities.
- Conduct comprehensive patient assessments prior to discharge.
- Provide education to patients and caregivers on disease management medications and care plans.
- Perform medication reconciliation to ensure accuracy and patient understanding.
- Schedule and confirm follow-up appointments with primary care providers or specialists.
- Collaborate with physicians social workers case managers and community providers with a focus on identifying Starling patients.
- Identify high-risk patients and implement interventions to prevent readmissions.
- Coordinate home health services medical equipment and community resources ensuring the best care with consultants
- Conduct post-discharge follow-up calls or visits to monitor patient progress.
- Maintain accurate documentation in the electronic medical record (EMR).
- Ensure compliance with Medicare Medicaid and Connecticut healthcare regulations.
Qualifications
Required
- Active Registered Nurse (RN) license in Connecticut
- Associate or Bachelors degree in Nursing
- 3 years clinical nursing experience (hospital case management discharge planning or care coordination)
Preferred
- BSN
- Certification such as Certified Case Manager (CCM) or Accredited Case Manager (ACM)
- Experience with population health or value-based care programs
Key Skills
- Care coordination
- Patient and family education
- Clinical assessment
- Discharge planning
- Interdisciplinary collaboration
- Documentation and compliance
About Our Commitment
Total Rewards at VillageMD
Our team members are essential to our mission to reshape healthcare through the power of connection. VillageMD highly values the critical role that health and wellness play in the lives of our team members and their families. Participation in VillageMDs benefit platform includes Medical Dental Life Disability Vision FSA coverages and a 401k savings plan.
Equal Opportunity Employer
Our Companyprovides equal employment opportunities (EEO) to all employees and applicants for employment without regard to and does not discriminate on the basis of race color religion creed gender/sex sexual orientation gender identity and expression (including transgender status) national origin ancestry citizenship status age disability genetic information marital status pregnancy military status veteran status or any other characteristic protected by applicable federal state and local laws.
Safety Disclaimer
OurCompanycares about the safety of our employees and Companydoes not use chat rooms for job searches or Companywill never request personal information via informal chat platforms or unsecure Companywill never ask for money or an exchange of money banking or other personal information prior to the in-person interview. Be aware of potential scams while job seeking. Interviews are conducted at selectOur Companylocations during regular business hours only. For information on job scams visit file a complaint at Experience:
IC
Key Skills
About Company
Summit Health has more than 2,500 providers, 12,000 employees, and over 340 locations in New Jersey, New York, Connecticut, Pennsylvania, and Central Oregon. Determine your health needs and choose the provider that best fits your needs.
