Full-Time/Part-Time
Full-Time
Location
UR Medicine Home Care Licensed Services
Salary
$73,652.80 to $103,854
Description
Position Summary:
The Transition of Care Innovation RN leads and delivers a payer-agnostic, nurse-led transition of care program for eligible older adults discharged from participating rural hospitals. The RN partners with patients, caregivers, hospital teams, primary care practices, pharmacists, home care, and community organizations to support a safe transition from hospital to home and reduce avoidable emergency department use and 30-day rehospitalizations. The RN coaches patients and caregivers to build the knowledge, confidence, and skills needed to manage medications, maintain an accurate patient-centered health record, complete timely follow-up, and recognize and respond to clinical red flags.
Responsibilities
Qualified individuals must be capable of performing the following essential duties and responsibilities, with or without reasonable accommodations:
• Identifies and screens patients using current program eligibility criteria and introduces the voluntary transition coaching program to eligible patients and caregivers.
• Collaborates with hospital discharge teams to identify risks, confirm the transition plan, and address barriers before or promptly after discharge.
• Completes timely post-discharge outreach and follow-up throughout the 30-day transition period, including a nurse visit or phone encounter when required by program standards.
• Supports patients and caregivers with medication self-management, use of a patient-centered health record, timely follow-up care, and recognition of and response to clinical red flags.
• Performs medication reconciliation and coaching; identifies discrepancies, access or adherence concerns, and high-risk issues; and coordinates resolution with pharmacists and providers.
• Assesses patient and caregiver understanding, health-related social needs, and barriers to recovery; provides education using teach-back and connects patients with appropriate clinical and community resources.
• Coordinates warm handoffs among primary care, specialists, home care, pharmacy, and community providers and escalates urgent clinical concerns according to established protocols.
• Documents outreach, assessments, interventions, referrals, escalations, goals, and outcomes in designated systems and supports planned completion or handoff at the end of the program.
• Tracks program measures, including enrollment, timeliness, follow-up care, emergency department use, and 30-day readmissions, and participates in case review, performance improvement, grant reporting, and partner meetings.
• Maintains competency in evidence-based transitional and geriatric care and provides flexible coverage and travel based on program needs.
Qualifications
Education & Experience - Applicants must possess the following qualifications or an equivalent combination of education and experience:
Education: Bachelor of Science in Nursing required. Experience: Minimum of 3-5 years of clinical nursing experience in home health, care management, acute care, geriatrics, population health, or a closely related setting. Experience with transitions of care, discharge planning, patient education, or quality improvement strongly preferred.
Licensure, Certification, and/or Credential Requirements
Current New York State Registered Professional Nurse license in good standing.
Knowledge, Skill, & Ability Requirements
• Strong clinical assessment, critical thinking, prioritization, and escalation skills.
• Knowledge of geriatric care, medication safety, chronic disease management, discharge planning, and community-based care.
• Ability to build collaborative relationships across hospitals, primary care, pharmacy, home care, and community organizations.
• Excellent written, verbal, organizational, and time-management skills, with the ability to manage a dynamic caseload and competing priorities.
• Ability to work independently while maintaining timely communication with interdisciplinary partners.
• Cultural humility and the ability to adapt education and care coordination to patient preferences, health literacy, language, access, and rural-community needs.
Technical & Systems/Equipment Proficiencies
• Electronic medical record documentation and secure clinical communication
• Data tracking, dashboards, and basic spreadsheet reporting
Microsoft Office (PowerPoint, Word, Excel, Teams, OneNote)
EMR experience
Other
• Valid driver's license and access to reliable transportation for travel within the designated rural service area.
• Ability to work a flexible schedule based on patient discharge timing and program needs, including occasional early evening or weekend coverage.
• This role provides transitional care coaching and coordination and does not replace emergency services, primary care, specialty care, or skilled home health services.
Expectations
Values: Perform all responsibilities in a manner that serves UR Medicine Home Care's Mission and upholds the organization's ICARE values of Integrity, Compassion, Accountability, Respect, and Excellence.
Safety: We expect our employees to follow all objectives for safe work performance and be responsible for their own actions and conduct. Our employees also play a significant role in the success or failure of our organization.
*Note: The above information on this job has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job.
This position is currently accepting applications.
