Primary Care Transition Of Care Nurse

Job Description

Job Description???? Transitions of Care Nurse (RN or LPN)

Greater Seacoast Community Health | Somersworth NH
Full-Time | Day Shift | Non-Exempt | Essential Role
Department: Quality & Population Health

• LPN: $31.00 – $37.00/hr (Based on experience)
• RN: $36.00 – $44.00/hr (Based on experience)

Be the Nurse Who Makes the Difference After Discharge

Care doesn’t stop when a patient leaves the hospital — and neither do we.

At Greater Seacoast Community Health (GSCH), our Transitions of Care Nurses are the vital link that ensures patients move safely, confidently, and successfully from hospitals or skilled nursing facilities back into primary care.

If you’re a nurse who thrives on coordination, patient education, and preventing avoidable readmissions — this role puts your clinical judgment, compassion, and organization to work where it matters most.

???? Why This Role Matters

• Reduce hospital readmissions and emergency department visits

• Improve patient outcomes through proactive follow-up and education

• Strengthen continuity of care across settings

• Build meaningful relationships with patients and families during critical transitions

You’ll collaborate closely with providers, hospitals, care managers, specialists, and community partners — all while helping patients feel supported, informed, and empowered.

???? What You’ll Do???? Care Coordination & Follow-Up

• Identify and track patients recently discharged from hospitals, EDs, or post-acute facilities

• Conduct timely post-discharge outreach to assess patient status and needs

• Perform medication reconciliation and identify barriers to adherence

• Ensure discharge instructions are understood and follow-up appointments are completed

???? Clinical Assessment & Patient Support

• Assess for red flags, worsening symptoms, or unmet clinical needs

• Provide education on diagnoses, medications, self-management, and warning signs

• Escalate concerns appropriately to primary care providers and care teams

• Support coverage for primary care nursing needs as required

???? Collaboration & Communication

• Coordinate care with hospitals, specialists, home health agencies, and community resources

• Communicate clearly and consistently with primary care providers

• Participate in interdisciplinary care team meetings and quality improvement efforts

???? Documentation & Quality Improvement

• Accurately document patient interactions and care plans in the EHR

• Track outcomes such as readmissions, ED utilization, and patient engagement

• Support value-based care initiatives and transitions-of-care regulatory requirements

✅ What We’re Looking For

• Registered Nurse (RN) or Licensed Practical Nurse (LPN)

• 1–3 years of experience in clinical practice, care management, population health, or transitional care

• Strong assessment, communication, and care coordination skills

• Ability to work independently while collaborating across teams

• Comfort with electronic health records and data tracking

• A patient-centered, calm, and solution-oriented approach

???? Our Values in Action

At GSCH, we believe healthcare should be:
Compassionate • Respectful • Collaborative • Accessible • High-Quality

We support our team members with a culture of trust, teamwork, and continuous improvement — because when our staff are supported, our patients thrive.

???? About Greater Seacoast Community Health

GSCH is a nonprofit network of community health centers serving New Hampshire’s Seacoast region. We provide integrated medical, dental, behavioral health, recovery, and social services — caring for the whole person, at every stage of life.

Ready to Help Patients Transition with Confidence?

If you’re a nurse who wants to improve outcomes, prevent readmissions, and play a critical role in coordinated care — we’d love to hear from you.

???? Apply today and help guide patients through safer, stronger transitions of care.

Greater Seacoast Community Health is an Equal Opportunity Employer.