Nurse Transition Coordinator

Catholic Health•West Islip, NY

2d•Onsite

About The Position

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.

Requirements

BSN from an accredited school of nursing (required)
Active NYS RN license
3–5 years of acute care nursing experience (Med/Surg, Critical Care, or Telemetry)
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.

Responsibilities

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).
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.
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.