Catholic Health System

Nurse Transition Coordinator

Catholic Health System • $135K — $162K *
West Islip, NY 11795In-Person
Hospitals & Medical Centers
Less than 5 years of experience
Today
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Job Overview by Ladders

Qualifications

  • BSN from an accredited school of nursing
  • Active NYS RN license
  • 3-5 years of acute care nursing experience (Med/Surg, Critical Care, or Telemetry)
  • Strong clinical judgment and prioritization skills
  • Proficient with EHR systems (Epic, Cerner preferred)

Responsibilities

  • Identify high-risk inpatients using EHR and risk stratification tools
  • Coordinate patient care, collaborating with the interdisciplinary team for safe discharge
  • Act as a liaison between patients, families, and healthcare providers
  • Assess and address barriers to care, developing tailored discharge plans
  • Coordinate post-acute care needs with relevant care teams
  • Educate patients and families on health maintenance and compliance
  • Monitor and report trends in hospital readmissions

Benefits

  • Education and professional development opportunities
  • Collaborative work environment
  • Focus on patient-centered care
  • Support for quality improvement initiatives
  • Participation in multidisciplinary care coordination
Full Job Description
Job Details

Job Summary

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.

Essential Responsibilities and Duties

Clinical Coordination & Navigation
  • 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)

Patient Education & Advocacy
  • 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


Quality Improvement & Strategic Collaboration
  • 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.

Qualifications & Requirements
  • Education: BSN from an accredited school of nursing (required)
  • Licensure: Active NYS RN license
  • Experience: 3-5 years of acute care nursing experience (Med/Surg, Critical Care, or Telemetry)

Skills & Competencies
  • 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.

Physical Requirements
  • Mobility: Ability to stand, sit, and walk in the nursing units to interview patients and families. Occasional stooping, kneeling, crouching, and reaching may be required to assist patients.


Posted Salary Range

USD $65.20 - USD $78.24 /Hr.

About Catholic Health System

Catholic Health is a non-profit healthcare system that provides care to Western New Yorkers across a network of hospitals, primary care centers, imaging centers, and several other community ministries. The system is comprised of four hospitals, including Mercy Hospital of Buffalo, Mount St. Mary's Hospital, Kenmore Mercy Hospital, and Sisters of Charity Hospital, as well as several other healthcare facilities. Catholic Health is committed to providing high-quality, compassionate care to all patients, regardless of their ability to pay.
Learn more about Catholic Health System
Size
17,000 employees
Industry
Healthcare
* Ladders Estimates

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