Transitional Care RN - Case Management - Full Time - Days

Company: Mohawk Valley Health System
Location: Utica
Posted on: January 17, 2026

Job Description:

Job Summary The RN - Transitional Care Coordinator is responsible for assessing patients that are medically complex and at high risk for readmission to ensure a successful transition from the hospital to community. The Transitional Care Coordinator RN is accountable to reduce the challenges that patients face post discharge and prevent hospital readmissions. Core Job Responsibilities Assess, plan, implement and evaluate the needs of patients for transitional care needs. Track and report variances in standards of care that impact our readmission rates. Coordinate the post-discharge workflow by anticipating potential gaps in care and education needs. Evaluate and follow-up for assigned patients who require medication reconciliation, adherence assessment, management of acute and chronic disease states, assessment of patient’s ability to perform self-care/instructions, coordination of post-discharge appointments and care coordination services. Coordinate processes designed to reduce readmissions with physicians, nursing staff, the patient and care givers. Implement post-discharge plans in accordance with criteria for Medicare, Medicaid coverage, HMO or private insurers. Collaborate with community agencies and service providers to meet transitional care needs. Perform other duties as required. Education/Experience Requirements REQUIRED: Bachelor's degree in Nursing or closely related field; or equivalent nursing experience. 3 years of clinical experience. Strong computer skills. PREFERRED: Case Management, Utilization Management and Quality Management experience Licensure/Certification Requirements REQUIRED: Current NYS Licensed Registered Professional Nurse. Disclaimer Qualified applicants will receive consideration for employment without regard to their age, race, religion, national origin, ethnicity, age, gender (including pregnancy, childbirth, et al), sexual orientation, gender identity or expression, protected veteran status, or disability. Successful candidates might be required to undergo a background verification with an external vendor. Job Details Req Id 94395 Department CASE MANAGEMENT Shift Days Shift Hours Worked 8.00 FTE 1 Work Schedule SALARIED GENERAL Employee Status A1 - Full-Time Union Non-Union Pay Range $67k - $106k/Annually

Keywords: Mohawk Valley Health System, Schenectady , Transitional Care RN - Case Management - Full Time - Days, Healthcare , Utica, New York