Transition Of Care Nurse
About The Position
At Greater Seacoast Community Health (GSCH), our Transitions of Care Nurses are the vital link that ensures patients move safely, confidently, and successfully from hospitals or skilled nursing facilities back into primary care. If you’re a nurse who thrives on coordination, patient education, and preventing avoidable readmissions — this role puts your clinical judgment, compassion, and organization to work where it matters most. You’ll collaborate closely with providers, hospitals, care managers, specialists, and community partners — all while helping patients feel supported, informed, and empowered. At GSCH, we believe healthcare should be: Compassionate • Respectful • Collaborative • Accessible • High-Quality We support our team members with a culture of trust, teamwork, and continuous improvement — because when our staff are supported, our patients thrive. GSCH is a nonprofit network of community health centers serving New Hampshire’s Seacoast region. We provide integrated medical, dental, behavioral health, recovery, and social services — caring for the whole person, at every stage of life. If you’re a nurse who wants to improve outcomes, prevent readmissions, and play a critical role in coordinated care — we’d love to hear from you.
Requirements
- Registered Nurse (RN) or Licensed Practical Nurse (LPN)
- 1–3 years of experience in clinical practice, care management, population health, or transitional care
- Strong assessment, communication, and care coordination skills
- Ability to work independently while collaborating across teams
- Comfort with electronic health records and data tracking
- A patient-centered, calm, and solution-oriented approach
Responsibilities
- Identify and track patients recently discharged from hospitals, EDs, or post-acute facilities
- Conduct timely post-discharge outreach to assess patient status and needs
- Perform medication reconciliation and identify barriers to adherence
- Ensure discharge instructions are understood and follow-up appointments are completed
- Assess for red flags, worsening symptoms, or unmet clinical needs
- Provide education on diagnoses, medications, self-management, and warning signs
- Escalate concerns appropriately to primary care providers and care teams
- Support coverage for primary care nursing needs as required
- Coordinate care with hospitals, specialists, home health agencies, and community resources
- Communicate clearly and consistently with primary care providers
- Participate in interdisciplinary care team meetings and quality improvement efforts
- Accurately document patient interactions and care plans in the EHR
- Track outcomes such as readmissions, ED utilization, and patient engagement
- Support value-based care initiatives and transitions-of-care regulatory requirements
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
Number of Employees
251-500 employees
