Care Transition Nurse

Summit Health CityMD•Hartford, CT

21d

About The Position

We’re 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 all. We 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: @summithealth.com, @citymd.net, @villagemd.com, @villagemedical.com, @westmedgroup.com, @starlingphysicians.com, or @bmctotalcare.com. 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.

Requirements

Active Registered Nurse (RN) license in Connecticut
Associate or Bachelor’s degree in Nursing
3+ years clinical nursing experience (hospital, case management, discharge planning, or care coordination)
Care coordination
Patient and family education
Clinical assessment
Discharge planning
Interdisciplinary collaboration
Documentation and compliance

Nice To Haves

BSN
Certification such as Certified Case Manager (CCM) or Accredited Case Manager (ACM)
Experience with population health or value-based care programs

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.