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Transitional Care Nurse Jobs (NOW HIRING)

Longleaf Hospice

Transitional Care Nurse

Atlanta, GA · On-site

The Transitional Care Nurse provides direct nursing care to patients, care coordination and education to patients, families and staff in general inpatient units in accordance with established ...

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How much do transitional care nurse jobs pay per hour?

As of May 28, 2026, the average hourly pay for transitional care nurse in the United States is $38.15, according to ZipRecruiter salary data. Most workers in this role earn between $28.37 and $36.06 per hour, depending on experience, location, and employer.

What Does a Transitional Care Nurse Do?

A transitional care nurse oversees the care of a patient as they move from one health care facility, such as a hospital or nursing home, to another facility or their home. The transitional care nurse ensures the relocation is as smooth as possible and helps the patient remain comfortable during the change. In this role, your job duties include creating a transitional care plan with the patient's physician and family members to determine when and how the move should be made. Once the patient is established in the new facility or back at home, you visit them regularly to assess their health and recovery. The transitional care model (TCM) of health care aims to reduce disruption in care, and thus lower the chances of patients relapsing and having to return to the hospital.

What are the key skills and qualifications needed to thrive as a Transitional Care Nurse, and why are they important?

To thrive as a Transitional Care Nurse, you need expertise in patient assessment, care coordination, and discharge planning, typically backed by an RN license and experience in acute or post-acute care settings. Familiarity with care management software, electronic health records (EHRs), and sometimes case management certifications like CCM are common requirements. Strong communication, problem-solving, and organizational skills help build trust with patients and collaborate across multidisciplinary teams. These skills are crucial for ensuring seamless transitions between care settings, reducing hospital readmissions, and improving patient outcomes.

What are some common challenges faced by a Transitional Care Nurse when coordinating patient care across different healthcare settings?

Transitional Care Nurses often encounter challenges such as fragmented communication between hospitals, primary care providers, and community services, which can impact the continuity of patient care. They must ensure that patients and families understand complex discharge instructions while also managing follow-up appointments and medication changes. Balancing a diverse caseload and addressing social determinants of health, such as transportation or home support, requires strong organizational and advocacy skills. Collaboration with multidisciplinary teams is essential to overcome these obstacles and promote positive patient outcomes.

What is a Transitional Care Nurse?

A Transitional Care Nurse is a registered nurse who specializes in helping patients transition between different levels of care, such as from hospital to home or to a rehabilitation facility. Their primary goal is to ensure continuity of care, reduce hospital readmissions, and promote positive health outcomes. They coordinate with healthcare teams, provide patient education, and support patients and their families throughout the transition process. Transitional Care Nurses play a vital role in managing medication, follow-up appointments, and addressing any concerns patients may have after discharge.

What is the difference between Transitional Care Nurse vs Home Health Nurse?

AspectTransitional Care NurseHome Health Nurse
CredentialsRN license, possibly certification in care managementRN license, often certification in home health or hospice
Work EnvironmentHospitals, clinics, transitional care settingsPatients' homes, community settings
Employer & IndustryHospitals, healthcare systems, transitional care agenciesHome health agencies, hospice providers

Transitional Care Nurses and Home Health Nurses both provide patient care, but Transitional Care Nurses focus on coordinating care during patient transitions from hospital to home or other settings, often working in healthcare facilities. Home Health Nurses primarily deliver care directly in patients' homes, managing ongoing health needs. While their roles overlap in patient education and care management, their work environments and specific responsibilities differ.

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Transitional Care Nurse jobs near you
Infographic showing various Transitional Care Nurse job openings in the United States as of May 2026, with employment types broken down into 13% As Needed, 74% Full Time, and 13% Part Time. Highlights an 100% In-person job distribution, with an average salary of $79,354 per year, or $38.2 per hour.
Registered Nurse - Transitional Care (FULL TIME)

Registered Nurse - Transitional Care (FULL TIME)

Global Transitional Care

San Diego, CA • On-site

Other

Posted 12 days ago

Job description

Company Description

Global Transitional Care (GTC) is the first third-party specialty group provider organization dedicated to providing comprehensive transitional care. Our mission is to enhance the care continuum and provide personalized clinical oversight for each individual patient.

GTC helps avoid complications and readmission to the hospital by helping to manage all aspects of care from inpatient stay to home for 30 days from date of discharge. Through a transitional care provider team, patients and their families will have access to a healthcare provider that is familiar to them and their case, 24 hours a day, 7 days a week.

GTC's goal in transitional care is to give the newly discharged patient and their healthcare team continuity of medical and post discharge care, further reducing adverse events, unnecessary return visits to the hospital or emergency room, and the knowledge to personally manage their own health condition.

Job Description

Under the supervision of an Advanced Practice Transitional Care Nurse (AP-TCN), the Transitional Care Nurse provides continuity of care throughout a patient's episode of acute care, from enrollment during hospitalization through a maximum of 31 days post hospitalization. In collaboration with other health team members, including the patient and family/caregiver, the TCN coordinates and implements the individualized plan of care. TCNs use their clinical judgment to determine the 'discharge readiness' of each patient. The Transitional Care Nurse also leads and supports care programs and research, and assists in marketing, business development, outreach, education, quality improvement, and other initiatives as needed.


Major Responsibilities:

Conducts face-to-face visits with patient in healthcare facilities and in patients' homes

Initiates telephone outreach and is available by phone during office and on-call hours 

Works independently and keeps physicians informed of patient status.

Uses all components of the Transitional Care Model and nursing process including assessment, triage, planning, implementing and evaluating care to meet the patients' needs.

Provides health maintenance, and medication and disease management education to patients and families/caregivers

Collects, organizes, documents, and analyzes data, synthesizing it into understandable information

Coordinates continuity of care, prevention and avoidance of complications, and close clinical treatment and management under the direction of the patient's primary healthcare provider(s) and AP-TCN

Effectively communicates, problem-solves, and maintains productive and effective interpersonal relationships while effectively prioritizing

Works with outside facilities and agencies on a routine basis, maintaining positive working relationships

Supports patients and their families, and provides compassionate care

Reports back to supervising AP-TCN and Director of Nursing

Qualifications

Authorization to work in the US

Associates Degree from an accredited Nursing Program

Five (5) or more years as an RN, preferably in acute care or case management setting, current CA RN license

BLS

Car, driver's license, auto insurance and safe driving history

English proficiency, bilingual a plus

Computer literacy (i.e. Microsoft Office Suite)

Must have a cell phone, computer, internet, and email access  


Preferred Qualifications:

BSN

Public Health and/or Case Management certification

Community Education Experience

Additional Information

All your information will be kept confidential according to EEO guidelines.

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