Registered Nurse RN – Transitional Care Coordinator

Registered Nurse RN – Transitional Care Coordinator at Yale New Haven Health in North Stamford, Stamford.

About the Role

This position supports patients as they move from hospital to home or other care settings, ensuring continuity of care and reducing readmissions. The nurse works closely with physicians, case managers, and community partners to create personalized discharge plans and provide education that empowers patients and families.

What You'll Do

• Assess patient needs and coordinate services such as home health, medication management, and follow‑up appointments.
• Develop and implement individualized transitional care plans in collaboration with the interdisciplinary team.
• Provide disease‑specific education, self‑management training, and medication reconciliation for patients and caregivers.
• Communicate with primary care providers, specialists, and community agencies to facilitate smooth handoffs.
• Monitor patient outcomes after discharge and intervene promptly when barriers to recovery are identified.
• Maintain accurate documentation in electronic health records and track metrics related to readmission rates and patient satisfaction.

What We're Looking For

• Active RN license in the state of Connecticut.
• Clinical experience in medical‑surgical, telemetry, or a related inpatient setting; prior exposure to case management or discharge planning is advantageous.
• Strong assessment, communication, and interpersonal skills to engage diverse patient populations.
• Ability to work independently while contributing to a collaborative team environment.
• Proficiency with electronic medical records and standard office productivity tools.
• Commitment to the principles of integrity, patient‑focused care, respect, accountability, and compassion.

About Yale New Haven Health

Yale New Haven Health is a leading integrated healthcare system dedicated to improving the health of the communities it serves. The organization fosters a culture where every team member is encouraged to uphold high standards of safety, quality, and compassionate service. Employees benefit from opportunities for professional growth, continuing education, and a supportive work environment that values teamwork and innovation.

How to Apply

To apply, complete your application directly on this page, or you'll be redirected to the employer's application platform to finish submitting there.