Holy Name Medical Center
RN, Care Transitions Coordinator
Holy Name Medical Center, Teaneck, New Jersey, United States
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RN, Care Transitions Coordinator
role at
Holy Name Medical Center .
Holy Name is New Jersey's only independent Catholic health system, comprising a 361-bed acute care hospital, a renowned cancer center, a state-of-the-art fitness center, a residential hospice, a prestigious nursing school, and an extensive physician network. Healing at Holy Name goes beyond medicine and technology – it is infused with faith, conviction, compassion, and a commitment to educating the next generation of healthcare professionals through various residency and educational programs. Our mission to provide care for the body, mind, and soul spans education, prevention, diagnosis, treatment, rehabilitation, and overall wellness. This is at the core of who we are and what we do, and we've done it across generations for nearly 100 years. Every innovation, medical breakthrough, and groundbreaking treatment is powered by some of the best minds in medicine and ensures nothing is left on the table or the road to recovery.
A Brief Overview The Care Transitions Coordinator is responsible for facilitating and coordinating services for patients through the continuum of care. The Care Transitions Coordinator ensures appropriate utilization of resources and safe delivery of care to all patients and provides quality and cost‑effective care that will lower Length of Stay (LOS) and decrease the fragmentation of services that can potentially compromise patient care. The Care Transitions Coordinator collaborates efforts as a team in order to perform one or more of the following roles: discharge planning and disease management of acute and chronic conditions, facility placement needs as needed and timely referrals and evaluations of all post‑acute care needs. The Care Transitions Coordinator plays a pivotal role for patients as part of the interdisciplinary team in order to ensure patient safety, quality of care and positive patient outcomes. Rotation of coverage for weekends and holidays will be required and is assigned throughout the year.
What You Will Do
Modification of plan of care, as necessary, to meet the ongoing needs of the patient
Communicate relevant information to third party payors and the care team.
Completion of all required documentation in patient records
Issues Notices of Non-Coverage per hospital policy.
Refer appropriate cases for social work intervention based on department criteria
Knowledgeable about Indigent Medication Programs
Verifies patient demographics and insurance information is correct
Expedites execution of plan of care for patients in Observation units.
Arranges transportation for patients slated for discharge.
Upholds compliance of regulatory standards for Observation patients including CMS requirement for Code 44.
Utilizes "Patient Choice" list for support services post discharge and documents.
Initiates home care referrals for VNS, orders durable medical equipment and arranges ambulance transportation as needed for patients prior to discharge or transfer to another facility.
Participates as an active, informative and cooperative team member of the health care staff by attending discharge rounds for case finding/follow up and participating in the discharge plan while acting as an advocate for the patient. Arranges family meetings to assist in discharge planning as indicated.
Other duties as assigned
Education Qualifications
Bachelor's Degree BSN Preferred or
Experience Qualifications
4-6 years 3-5 years experience in an acute care setting Required and
Disease Management and Discharge planning experience Preferred
Knowledge, Skills, And Abilities
Analytical and problem solving along with excellent verbal and written communication skills.
Licenses and Certifications
RN -- Registered Nurse -- State Licensure and/or Compact State Licensure Upon Hire Required and
CCM -- Certified Case Manager Upon Hire Preferred
Benefits At Holy Name, we believe in rewarding every team member with more than a paycheck — we invest in your future and well‑being. Full‑time and part‑time employees have access to a comprehensive benefits package designed to support your health, financial security, and quality of life. We offer low‑cost medical coverage with generous employer contributions, dental and vision plans, discounted prescriptions, and access to on‑site child care. Additional benefits include 401(k) matching, tuition reimbursement, paid time off, flexible spending accounts, legal and voluntary coverage options, life insurance, and free on‑site parking. If you are hired at Holy Name, your final base compensation will be determined based on factors such as employment status (Full/Part-Time or Per Diem), skills, education, and/or experience. In addition to those factors – we believe in the importance of pay equity and consider any internal equity of our current team members as a part of any final offer. Pay Range: $93,600.00 - $109,200.00.
Holy Name is an Equal Opportunity Employer.
Seniority Level Mid‑Senior level
Employment Type Part‑time
Job Function Health Care Provider
Industries Hospitals and Health Care
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RN, Care Transitions Coordinator
role at
Holy Name Medical Center .
Holy Name is New Jersey's only independent Catholic health system, comprising a 361-bed acute care hospital, a renowned cancer center, a state-of-the-art fitness center, a residential hospice, a prestigious nursing school, and an extensive physician network. Healing at Holy Name goes beyond medicine and technology – it is infused with faith, conviction, compassion, and a commitment to educating the next generation of healthcare professionals through various residency and educational programs. Our mission to provide care for the body, mind, and soul spans education, prevention, diagnosis, treatment, rehabilitation, and overall wellness. This is at the core of who we are and what we do, and we've done it across generations for nearly 100 years. Every innovation, medical breakthrough, and groundbreaking treatment is powered by some of the best minds in medicine and ensures nothing is left on the table or the road to recovery.
A Brief Overview The Care Transitions Coordinator is responsible for facilitating and coordinating services for patients through the continuum of care. The Care Transitions Coordinator ensures appropriate utilization of resources and safe delivery of care to all patients and provides quality and cost‑effective care that will lower Length of Stay (LOS) and decrease the fragmentation of services that can potentially compromise patient care. The Care Transitions Coordinator collaborates efforts as a team in order to perform one or more of the following roles: discharge planning and disease management of acute and chronic conditions, facility placement needs as needed and timely referrals and evaluations of all post‑acute care needs. The Care Transitions Coordinator plays a pivotal role for patients as part of the interdisciplinary team in order to ensure patient safety, quality of care and positive patient outcomes. Rotation of coverage for weekends and holidays will be required and is assigned throughout the year.
What You Will Do
Modification of plan of care, as necessary, to meet the ongoing needs of the patient
Communicate relevant information to third party payors and the care team.
Completion of all required documentation in patient records
Issues Notices of Non-Coverage per hospital policy.
Refer appropriate cases for social work intervention based on department criteria
Knowledgeable about Indigent Medication Programs
Verifies patient demographics and insurance information is correct
Expedites execution of plan of care for patients in Observation units.
Arranges transportation for patients slated for discharge.
Upholds compliance of regulatory standards for Observation patients including CMS requirement for Code 44.
Utilizes "Patient Choice" list for support services post discharge and documents.
Initiates home care referrals for VNS, orders durable medical equipment and arranges ambulance transportation as needed for patients prior to discharge or transfer to another facility.
Participates as an active, informative and cooperative team member of the health care staff by attending discharge rounds for case finding/follow up and participating in the discharge plan while acting as an advocate for the patient. Arranges family meetings to assist in discharge planning as indicated.
Other duties as assigned
Education Qualifications
Bachelor's Degree BSN Preferred or
Experience Qualifications
4-6 years 3-5 years experience in an acute care setting Required and
Disease Management and Discharge planning experience Preferred
Knowledge, Skills, And Abilities
Analytical and problem solving along with excellent verbal and written communication skills.
Licenses and Certifications
RN -- Registered Nurse -- State Licensure and/or Compact State Licensure Upon Hire Required and
CCM -- Certified Case Manager Upon Hire Preferred
Benefits At Holy Name, we believe in rewarding every team member with more than a paycheck — we invest in your future and well‑being. Full‑time and part‑time employees have access to a comprehensive benefits package designed to support your health, financial security, and quality of life. We offer low‑cost medical coverage with generous employer contributions, dental and vision plans, discounted prescriptions, and access to on‑site child care. Additional benefits include 401(k) matching, tuition reimbursement, paid time off, flexible spending accounts, legal and voluntary coverage options, life insurance, and free on‑site parking. If you are hired at Holy Name, your final base compensation will be determined based on factors such as employment status (Full/Part-Time or Per Diem), skills, education, and/or experience. In addition to those factors – we believe in the importance of pay equity and consider any internal equity of our current team members as a part of any final offer. Pay Range: $93,600.00 - $109,200.00.
Holy Name is an Equal Opportunity Employer.
Seniority Level Mid‑Senior level
Employment Type Part‑time
Job Function Health Care Provider
Industries Hospitals and Health Care
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