Nurse Manager - Transition of Care

Job Description

Position Overview

The Nurse Manager, Transitions of Care provides clinical and operational oversight for the Transitions of Care department. This working manager role supports safe, timely, and coordinated care for patients moving from hospitals, emergency departments, skilled nursing facilities, and other care settings to community-based care, while combining departmental leadership with direct nursing and care-coordination support based on patient complexity, staffing needs, and departmental volume.

Job Competencies

• Oversee daily department operations, including staffing, coverage, assignments, work queues, and patient prioritization.
• Monitor hospital alerts, referrals, outreach queues, and unresolved care needs to support timely follow-up and productivity aligned with value-based care.
• Assign and adjust workloads based on patient acuity, complexity, discharge volume, and staff capacity.
• Lead team huddles and case reviews to identify urgent needs, address workflow barriers, and establish daily priorities.
• Develop and maintain standardized workflows, procedures, and escalation pathways.
• Provide operational coverage and clinical support during staff absences, increased demand, or complex patient situations.
• Escalate staffing, resource, patient-safety, and operational concerns to the supervising nursing leader.
• Oversee nursing assessment, post-discharge outreach, medication review and reconciliation workflows, patient education, follow-up coordination, and care-plan documentation.
• Ensure clinical activities remain within staff licensure, competency, organizational policy, and authorized protocols.
• Supervise assigned nursing and support staff, setting clear expectations for clinical practice, productivity, documentation, and patient-centered service.
• Participate in recruitment, interviewing, hiring, and orientation; conduct performance evaluations and staff competencies; and coordinate training, coaching, and professional development.
• Monitor schedules, attendance, timekeeping, and coverage in accordance with organizational policy.
• Coach staff to engage and re-engage patients in primary care and behavioral health services through performance check-ins and scripting.
• Track patient satisfaction, retention, Transitions of Care visits completed within seven days, and appointment-triage needs.
• Participate in health information exchange reviews to support the flow of clinical data from across New York State.
• Support sites in maintaining hospital relationships and addressing gaps in receiving hospital discharge summaries.
• Ensure eligible patients are referred to and billed for appropriate care-management services.
  
  

Key Partnerships

Collaborate with nursing leadership, primary care teams, hospital partners, and care-management programs to strengthen post-discharge follow-up, address barriers to care, and support continuity across the care continuum.

Qualifications

• Current, unrestricted Registered Nurse license in New York.
• Active CPR/BLS
• Bachelor’s degree required, Master's degree in nursing preferred.
• Three to five years of progressive nursing experience, including clinical practice relevant to transitions of care, care management, ambulatory nursing, or population health.
• Prior experience as a nurse manager, nursing supervisor, clinical program leader, or director of nursing education preferred.
• Experience supervising nursing staff, support staff, or interdisciplinary teams.
• Strong written, verbal, organizational, interpersonal, leadership, and data-analysis skills.
  
  

Salary Range: $112,253.75/year - $121,140.47/year