Location
West Islip, NY, United States
Posted
July 27, 2026
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 individ...
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 individ...