Care Transitions Nurse (RN)

Urban Health Plan•Bronx, NY

2d•Remote

About The Position

The Bilingual English/Spanish Care Transitions Nurse (RN) is responsible for supporting patients during critical transitions of care, particularly following emergency room visits, hospital discharges, and specialty care episodes. This role ensures timely follow-up, medication reconciliation, care coordination, and patient education to reduce readmissions and prevent gaps in care. The Care Transition Nurse works closely with primary care providers, specialists, care management teams, and community partners to ensure continuity of care and improve health outcomes for high-risk and medically complex patients. This role supports the organization's population health, quality improvement, and value-based care initiatives by facilitating safe transitions and promoting patient engagement in ongoing care. As part of the Virtual Care Center- this role is a fully remote position. Although remote, incumbents are required to engage in in person and Bronx-based service throughout training period, and throughout employment for trainings and meetings when requested. Required schedule included Monday through Friday 9am-6pm shift.

Requirements

Associates or Bachelors in Nursing is required
NYS Licensed Registered Nurse is required
Minimum of 2-5 years of clinical nursing experience is required in ambulatory care, community health, or related setting
Bilingual Spanish/English is required
Strong care coordination and patient communication skills
Knowledge of hospital discharge processes and transitional care management
Ability to identify clinical and social determinants of health impacting care
Proficiency in electronic health records and care documentation
Ability to work collaboratively across multidisciplinary teams

Responsibilities

Transitional Care Management & Patient Follow-Up Conduct outreach to patients following hospital or emergency department discharge
Complete Transitional Care Management (TCM) workflows in accordance with CMS guidelines
Ensure patients receive timely follow-up appointments with primary care providers or specialists
Facilitate specialty care coordination by assisting patients in navigating referrals, scheduling appointments, and ensuring appropriate follow-up with specialty providers.
Perform medication reconciliation and assess for medication adherence and safety concerns
Identify and address barriers to care, including transportation, social needs, and access issues
Perform medication reconciliation and assess for medication adherence and safety concerns
Identify and address barriers to care, including transportation, social needs, and access issues
Care Coordination & Continuity of Care Coordinate care between hospital systems, primary care providers, specialists, and community resources.
Review discharge summaries and hospital documentation to ensure appropriate follow-up care
Facilitate referrals, diagnostic testing, and specialty appointments as needed
Support patients in understanding discharge instructions and treatment plans
Ensure patients do not fall through gaps in care during transitions
High-Risk Patient Management Identify high-risk patients based on clinical, social, and utilization risk factors
Provide additional monitoring and outreach for patients at risk of readmission
Collaborate with care managers, CHWs, behavioral health providers, and social services to address complex patient needs
Patient Education & Engagement Provide patient-centered education regarding diagnosis, medications, warning signs, and follow-up care
Promote patient self-management and adherence to treatment plans
Encourage ongoing engagement with primary care services
Address health literacy and cultural considerations to improve understanding and compliance
Data Documentation & Reporting Document patient encounters and care coordination activities in the EHR
Track outreach efforts, successful contacts, and follow-up outcomes
Support reporting for Transitional Care Management (TCM) billing and quality measures
Contribute to organizational reporting related to readmission reduction and care continuity
Quality Improvement & Population Health Participate in initiatives aimed at reducing avoidable hospitalizations and emergency room utilization
Identify patterns or barriers affecting successful transitions of care
Collaborate with leadership to improve workflows related to discharge follow-up and care coordination
Support quality improvement initiatives related to patient access and care continuity
Collaboration & Team Integration Work closely with providers, care management teams, call center staff, and telehealth teams to coordinate patient care
Communicate patient updates and concerns to primary care teams in a timely manner
Participate in multidisciplinary meetings focused on high-risk patient management and care planning

Benefits

Fully funded Health Insurance for you/ 73.5% funded Health Insurance for your family
Dental, Vision, and Prescription Coverage
401(k) Retirement Savings (including 3% annual employer contribution)
Comprehensive time off including paid vacation, personal time, sick time, and paid holidays (including your birthday!)
Flex Spending Accounts (Health care, Dependent Care, and Commuter Benefits)
Entertainment Discount Programs
Employee Assistant Program
Eligibility to apply for Public Service Loan Forgiveness Program (PSLF)
Fitness Discounts and Perks through our medical plan.
$50,000 term life Insurance