Job Description

Job Description

Job ID#:

4351

Job Category:

Nursing

Position Summary:

The 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:

• 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

Key Duties:

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

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: 

• 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

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.

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