care transitions nurse

URBAN HEALTH PLAN, INC.

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 Job Description
 
 
 
 
 Position Summary:
 
 
 
 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.
 
 
 
 Minimum Qualifications
 
 
 
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 Associates or Bachelors in Nursing is required.
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 NYS Licensed Registered Nurse is required.
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 Minimum of 2-5 years of clinical nursing experience is required in ambulatory care, community health, or related setting.
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 Bilingual Spanish/English is required.
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 Strong care coordination and patient communication skills
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 Knowledge of hospital discharge processes and transitional care management
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 Ability to identify clinical and social determinants of health impacting care
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 Proficiency in electronic health records and care documentation
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 Ability to work collaboratively across multidisciplinary teams
 
 
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 </ul>
 
 Key Duties
 
 
 
 
 Transitional Care Management &amp; Patient Follow-Up
 
 
 
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 Conduct outreach to patients following hospital or emergency department discharge
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 Complete Transitional Care Management (TCM) workflows in accordance with CMS guidelines
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 Ensure patients receive timely follow-up appointments with primary care providers or specialists
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 Facilitate specialty care coordination by assisting patients in navigating referrals, scheduling appointments, and ensuring appropriate follow-up with specialty providers.
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 Perform medication reconciliation and assess for medication adherence and safety concerns
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 Identify and address barriers to care, including transportation, social needs, and access issues
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 Perform medication reconciliation and assess for medication adherence and safety concerns
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 Identify and address barriers to care, including transportation, social needs, and access issues
 
 
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 </ul>
 
 Care Coordination &amp; Continuity of Care
 
 
 
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 Coordinate care between hospital systems, primary care providers, specialists, and community resources.
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 Review discharge summaries and hospital documentation to ensure appropriate follow-up care
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 Facilitate referrals, diagnostic testing, and specialty appointments as needed
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 Support patients in understanding discharge instructions and treatment plans Ensure patients do not fall through gaps in care during transitions
 
 
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 </ul>
 
 High-Risk Patient Management
 
 
 
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 Identify high-risk patients based on clinical, social, and utilization risk factors
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 Provide additional monitoring and outreach for patients at risk of readmission
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 Collaborate with care managers, CHWs, behavioral health providers, and social services to address complex patient needs
 
 
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 Patient Education &amp; Engagement
 
 
 
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 Provide patient-centered education regarding diagnosis, medications, warning signs, and follow-up care
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 Promote patient self-management and adherence to treatment plans
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 Encourage ongoing engagement with primary care services
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 Address health literacy and cultural considerations to improve understanding and compliance
 
 
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 Data Documentation &amp; Reporting
 
 
 
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 Document patient encounters and care coordination activities in the EHR
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 Track outreach efforts, successful contacts, and follow-up outcomes
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 Support reporting for Transitional Care Management (TCM) billing and quality measures
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 Contribute to organizational reporting related to readmission reduction and care continuity
 
 
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 </ul>
 
 Quality Improvement &amp; Population Health
 
 
 
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 Participate in initiatives aimed at reducing avoidable hospitalizations and emergency room utilization
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 Identify patterns or barriers affecting successful transitions of care
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 Collaborate with leadership to improve workflows related to discharge follow-up and care coordination
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 Support quality improvement initiatives related to patient access and care continuity
 
 
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 Collaboration &amp; Team Integration
 
 
 
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 Work closely with providers, care management teams, call center staff, and telehealth teams to coordinate patient care
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 Communicate patient updates and concerns to primary care teams in a timely manner
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 Participate in multidisciplinary meetings focused on high-risk patient management and care planning
 
 
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 </ul>
 
 Starting Compensation:
 
 Minimum $86,560 per year; Maximum $98,560 per year contingent on degree and years of nursing experience.
 
 
 
 As a full time associate at Urban Health Plan, you'll enjoy:
 
 
 
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 Fully funded Health Insurance for you/ 73.5% funded Health Insurance for your family
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 Dental, Vision, and Prescription Coverage
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 401(k) Retirement Savings (including 3% annual employer contribution)
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 Comprehensive time off including paid vacation, personal time, sick time, and paid holidays (including your birthday!)
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 Flex Spending Accounts (Health care, Dependent Care, and Commuter Benefits)
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 Entertainment Discount Programs
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 Employee Assistant Program
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 Eligibility to apply for Public Service Loan Forgiveness Program (PSLF)
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 Fitness Discounts and Perks through our medical plan.
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 $50,000 term life Insurance
 
 
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 </ul>
 
 About Urban Health Plan
 
 
 
 At Urban Health Plan (UHP) our mission is to continuously improve the health of communities and the quality of life of the people we serve by providing affordable, comprehensive, quality, primary and specialty health care and by assuring the performance and advancement of innovative best practices. At UHP, our commitment to provide patient-centered, holistic, quality health care, is part of a tradition started by our founder, Dr. Richard Izquierdo, 50 years ago. That tradition continues today by promoting excellence in everything that we do.
 
 
 
 UHP is an equal opportunity employer. M/F/D/V. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex, sexual orientation, gender identity, gender expression, national origin/ancestry, citizenship status, disability, age, marital or family status, and military or veteran status.
 
 
 
 Job Requirements
</div>

Care Transitions Nurse (RN)

Advocate Aurora Health

Part Time Care Transitions Nurse - This is a part-time remote role that requires high-speed internet and requires some evening and weekend coverage. Care Transitions role for both 30 and 90-day programs Medicare/ACO patient population/Medicare FFS program post-hospital discharge.
 
Position Requirements: Bachelor`s Degree in Nursing. Typically requires 2 years of experience in nursing in an acute care or community setting with an emphasis in palliative care or senior services. Excellent written and verbal communication skills. Strong organizational analytical and problem-solving skills. Ability to educate clinical staff and the community. Ability to work well with physicians and other healthcare professionals. Ability to work in a team-based multidisciplinary environment. Registered Nurse license issued by the state in which the team member practices. May need to operate a motorized vehicle to facilitate home visits as appropriate. Must be able to sit stand and walk without restriction. Must have the ability to move about in confined spaces including bending twisting kneeling squatting and occasionally reaching one or both arms overhead. Must be able to concentrate on detailed information, tasks and functions for prolonged periods of time. Must be able to speak clearly and hear in order to communicate in-person or via telephone.
 
This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties. Purpose: Responsible for ensuring an efficient and coordinated hospital discharge and transition process for patients recently hospitalized or treated in the emergency room that are at high risk for increased use of healthcare resources. Accountabilities: Identifies the needs of patients and families and coordinates internal and external community resources within the first month of hospital discharge.

Care Transitions Nurse - WEEKENDS

Texas Health Resources

<div><div>Care Transition RN
Bring your passion to Texas Health where we are Better +Together
Work location: Texas Health Cleburne 201 Walls Dr. Cleburne, TX 76033
Work hours: PRN Days - Between 8:00 am - 5p to cover sick/pto time. Occasional weekends required(Saturday on site 8am-5p and Sunday can be remote or on site between 8am-5p)</div><div>
Department highlights:
Robust Unit Based Council (UBC) and engaged leadership team<ul><li> The Care Transition team ensures that patients are transitioned to appropriate level of care in a timely and effective manner. Provides education, care and resources to patients across various specialties to identify transition needs and discuss post- acute care options</li><li> Manageable Case Load</li><li> Team that works together to ensure work life balance for all</li></ul>
Here&rsquo;s What You Need
<ul><li> Bachelor of Science in Nursing required. (Individuals hired as CTRN prior to May 11, 2017 will be grandfathered to the CTRN position with an RN, at the entity they were employed at on May 11, 2017)</li><li> 3 years of experience as a staff nurse in an acute care hospital required.</li><li> 1 year discharge planning / care management preferred.</li><li> RN Registered Nurse required upon hire</li><li> CPR &ndash; Cardiopulmonary Resuscitation required upon hire</li><li> ACM &ndash; Accredited Case Manager preferred or</li><li> CCM &ndash; Certified Case Manager or other ANCC upon hire preferred.</li></ul>
Skills<ul><li> Working knowledge of medical necessity criteria preferred</li><li> Knowledge of MS Outlook and Office (Word, Excel)</li><li> Customer Service Skills</li><li> Ability to engage in complex clinical decision -making</li><li> Strong oral and written communication skills</li><li> Strong commitment to interdisciplinary collaboration</li><li> Critical thinking, analysis and conflict resolution skills</li><li> Ability to prioritize and meet deadlines</li></ul>
Position Responsibilities<ul><li> Ensure patients are transitioned to appropriate levels of care in a timely and effective manner to decrease hospital length of stay</li><li> Reviews and works to reduce readmission rates for assigned patients</li><li> Identify high risk patients and promotes discussion and assists in the identification of a primary care physician (PCP) for patients</li><li> Completes Transition Evaluations on patients within 24 hours of identification and begins discharge planning</li><li> Interviews and assesses patients and caregivers as part of the transition evaluation</li><li> Identifies transition needs and discusses funding of post-transition care with patients and caregivers</li><li> Delivers Medicare forms to designated recipients per Medicare guidelines</li></ul>
Additional perks of being a Texas Health Nurse<ul><li> Benefits include 401k, PTO, medical, dental, Paid Parental Leave, flex spending, tuition reimbursement, Student Loan Repayment Program as well as several other benefits.</li><li> Delivery of high quality of patient care through nursing education, nursing research and innovations in nursing practice.</li><li> Strong Unit Based Council (UBC).</li><li> A supportive, team environment with outstanding opportunities for growth.</li><li> Explore our Texas Health careers site for info like Benefits, Job Listings by Category, recent Awards we&rsquo;ve won and more.</li></ul>
Do you still have questions or concerns? Feel free to email your questions to recruitment@texashealth.org. #LI-CR1</div></div>

Care Transition RN - PRN Days

Integrated Wellness Consultants

Now Hiring: Nurse Practitioner (Hospital team) Location: Aurora, IL &ndash; Mercy HospitalIgnite Hospitalists is seeking a dedicated and motivated Nurse Practitioner to join our hospital team at Mercy Hospital in Aurora, Illinois. This position offers the opportunity to work in a collaborative hospital setting alongside experienced physicians and clinical staff.Position Overview:The Nurse Practitioner will provide comprehensive inpatient medical care, managing acute and chronic conditions while coordinating care with physicians and multidisciplinary teams.Key Responsibilities:<ul><li>Perform comprehensive history and physical examinations</li><li>Evaluate, diagnose, and manage acute and chronic medical conditions</li><li>Admit, round on, and manage hospitalized patients</li><li>Order and interpret labs, imaging, and diagnostic tests</li><li>Develop and implement evidence-based treatment plans</li><li>Prescribe medications and therapies as appropriate</li><li>Coordinate care with specialists, nursing staff, and case management</li><li>Participate in discharge planning and transitions of care</li><li>Document patient encounters accurately and timely in EMR</li><li>Provide patient and family education</li></ul>Qualifications:<ul><li>Active Illinois Nurse Practitioner license</li><li>Board Certification (FNP, AGNP, or ACNP)</li><li>Hospital experience preferred but not required</li><li>Strong clinical assessment and decision-making skills</li><li>Ability to work independently and collaboratively</li></ul>What We Offer:<ul><li>Competitive compensation</li><li>Supportive physician-led team environment</li><li>Opportunity for professional growth</li></ul>Interested candidates may submit their CV to: support@iwcgroup.orgPay: $123,575.54 - $135,930.59 per yearWork Location: In person

Nurse Practitioner

Longevity Health

<div>Join us in transforming healthcare. 


Longevity Health&rsquo;s Statement of Purpose is to improve the health and quality of life of nursing home residents by caring for their unique medical, social, and emotional needs. 


Job Summary:

This role blends hands-on patient care with administrative coordination in long-term care settings. The RN Field Coordinator is instrumental in supporting Longevity Health&rsquo;s Institutional Special Needs Plan (I-SNP), ensuring smooth transitions of care, and educating facility staff on our clinical model. The RN Field Coordinator will travel to various Nursing Homes upon request and assignment by the Market Director of Clinical Services (MDCS). 
Key Tasks and Responsibilities:
<ul><li>
Conduct in-person visits at multiple nursing homes to assist Advanced Practice Providers (Nurse Practitioners) with clinical and administrative tasks.</li><li>
Use facility EMRs to prescreen new enrollees and identify continuity of care needs, including access to external specialists.</li><li>
Collaborate with clinical and operations teams to oversee member appointments and ensure timely communication with providers and facility staff.</li><li>
Support transitions of care, assist with prior authorization requests, and help members access services outside the nursing facility.</li><li>
Communicate with patients, families, and physicians as delegated by nurse practitioners.</li><li>
Lead orientation sessions for new and existing nursing homes to educate staff on Longevity Health Plan model of care.</li><li>
Help initiate telehealth services in newly onboarded facilities, including staff education and follow-up.</li><li>
Maintain proficiency in the Longevity Health Plan electronic medical record system and assist with data entry when needed.</li><li>
Participate in clinical meetings and contribute to hospitalization review sessions.</li><li>
Perform additional responsibilities as assigned by the Market Director of Clinical Services (MDCS), based on caseload and team needs.</li></ul>

Credentials &amp; Coverage:
<ul><li>
Licensed registered professional nurse in good standing.</li><li>
Valid state drivers&rsquo; license with a good driving record and proof of automobile insurance required.</li><li>
Auto insurance coverage as required by your state of residence. New employees will be responsible for providing proof of coverage prior to hire and on an ongoing basis.</li></ul> 


Education and Training:
<ul><li>
Associate degree in nursing required, bachelor&rsquo;s degree in nursing or other healthcare related discipline but must be a licensed professional registered nurse.</li></ul>

Knowledge and Experience:
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Nursing home background or health plan case management experience preferred.</li><li>
Minimum 2 years&rsquo; experience as a Registered Nurse.</li><li>
Excellent verbal and written communication skills.</li><li>
Excellent computer skills, EMR/clinical Platform/MS Office Products.</li><li>
Knowledge of the challenges and opportunities to serve the long-term nursing home population.</li><li>
Able to travel.</li><li>
Required to have managed care coordination background/experience.</li></ul>
Company Overview 
Longevity Health is a national provider of Institutional Special Needs Plans (I-SNP), created to meet the complex healthcare needs of nursing home residents. Since our founding in 2018, we've expanded our services across several states and formed strategic partnerships to deliver high-quality, patient-centered care. We are actively growing, with plans to continue expanding our services across the nation. 


Longevity Health is an Equal Opportunity Employer. We value diversity and encourage applicants of all backgrounds to apply. 


COVID-19 Vaccination Policy

Longevity Health follows federal and state regulations regarding COVID-19 vaccinations. Some facilities may still require staff vaccinations to protect the health of residents. Applicants will be required to provide proof of vaccination, or an approved exemption, where applicable. 


If you are passionate about healthcare and ready to help us drive change in long-term care, apply now to join the Longevity Health team! 


#LHP2026A</div>

RN Field Coordinator

Medical Director Services PC

Job Summary:Nurse Practitioner (Geriatrics) Experience Preferred,(Flexible Hours) We are looking for a dedicated Provider to join our healthcare team. The ideal candidate should have a strong nursing background and expertise in various medical treatments and care settings. As a Nurse Practitioner/ Physicians Assistant, you will play a crucial role in providing high-quality patient care and collaborating with other healthcare professionals.Duties: - Conduct thorough patient assessments to develop comprehensive care plans. - Administer treatments, including acute pain management. - Collaborate closely with physicians and healthcare team members for coordinated patient care. - Utilize ICD-9 coding for accurate documentation and billing purposes. - Engage in discharge planning to ensure smooth transitions for patients.Experience: - Experience in diverse patient care settings such as hospitals or assisted living facilities. - Strong communication and interpersonal skills to interact effectively with patients and colleagues. - Ability to work efficiently in a fast-paced environment while maintaining high-quality care standards.This position offers competitive compensation and benefits. If you are a skilled Provider passionate about delivering exceptional patient care and making a positive impact, we invite you to apply for this rewarding opportunity.Pay: $120,000.00 - $157,000.00 per yearBenefits:<ul><li>401(k)</li><li>Dental insurance</li><li>Flexible schedule</li><li>Health insurance</li><li>Paid time off</li><li>Vision insurance</li></ul>License/Certification:<ul><li>NP or PA License (Required)</li></ul>Work Location: In person

Nurse Practitioner (Geriatrics) Experience Preferred,(Flexible Hours)

Nurse Practitioner- LTC

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