Care Transitions Nurse

• Baltimore, MD
• SINAI HOSPITAL
• CARE TRANSITIONS
• Full-time - Day shift - 8:00am-4:30pm
• RN Other
• 88943
• $38.20-$59.21 Experience based
• Posted: April 12, 2025

Summary

POSITION SUMMARY: The Care Transitions Nurse will provide intensive case management to high-risk patients post discharge. The Care Transitions Nurse is directly involved in managing the multiple elements that comprise a person's successful transition from hospital to home. He/she will conduct home visits, provide health education, assist in the coordination of health care needs of all complex cases, and develop professional referral relationships to ensure patient needs are met.

RESPONSIBILITIES:

Provides assessment of and discharge planning to the adult and geriatric populations enrolled in the Transitions program.
• Receives high risk referrals via handoff from the Patient Care Liaisons.
• Takes the lead in ensuring the continuity and consistency of care extending beyond the inpatient setting. Serves as a liaison to acute care hospitals and post-acute care services to facilitate comprehensive discharge planning and follow up care.
• Meets with patient/family in the hospital setting to initiate relationship, enroll patient in program, schedule home visit, and reinforce teaching.
• Meets with patient in the home setting 24-48 hours of discharge from the hospital to assess any immediate needs or issues, reinforce discharge instructions, medication reconciliation, assess self-management skills, evaluate the home for safety, assess for the presence or absence of a support system, identify barriers to care, and ensure timely outpatient follow up.
• Participates in data collection as directed. Develops effective working relationships with Physicians, Nursing, other ancillary departments, and referral sources.
• Meets with patient in the home setting 24-48 hours of discharge from the hospital to assess any immediate needs or issues, reinforce discharge instructions, medication reconciliation, assess self-management skills, evaluate the home for safety.

REQUIREMENTS:

• Basic professional knowledge; equivalent to a Bachelor's degree; working knowledge of theory and practice within a specialized field
• BSN preferred; ADN required
• 3-5 years related experience; Prior experience with inpatient case management/discharge planning strongly preferred
• Registered Nurse License - Current Maryland license or eligibility to obtain Maryland license
• American Heart Association BLS
• Case Mgmt cert preferred within 3-5 yrs of hire

Additional Information