Clinical Transitions Nurse

Partially Remote

Partially Remote: Applicants must be within a commutable distance of Troy, NY, USA

UCM Digital Health (UCM) is a leading innovator in the digital health space, founded in 2015 by emergency medicine providers with the vision that all care should begin digitally. Our mission is to put the patient first with a best-in-class digital experience backed by emergency medicine expertise. Our digital front door platform, integrated technology, and 24/7 telehealth treat, triage and care coordination seamlessly connect digital and physical healthcare for patients. We deliver the right care, at the right time and place, and at the right cost for our more than 2 million patients and over 600 clients and growing.

Our solution is designed to lower costs, improve outcomes and provide a better patient experience. More than a digital front door, UCM brings together clinical expertise, advanced technology, and compassionate care to offer powerful advantages for health plans, employers, patients and providers.

We are looking for candidates who share our mission to put the patient first and our values of honesty, compassion, inquisitiveness, fearlessness, accountability, and teamwork. If you have an entrepreneurial spirit, thrive in a fast paced environment, and are ready to contribute to a growing company, come join our team! This is a great opportunity to be part of changing the game in healthcare!

Position Summary:

UCM Digital Health has a terrific opportunity for a dynamic Clinical Transitions Nurse (CTN) to join our team at a rapidly growing telehealth company. The CTN is responsible for ensuring that patients identified for the readmissions program receive a highly coordinated, high quality and cost-efficient health outcome. This position will involve on-site and remote management of patients, on-site and remote meetings with post-acute providers and serving as a key conduit of information among all providers for seamlessly integrated care. The Clinical transitions nurse provides support to 1) the patient, family/caregivers 2) the hospital care team 3) community based clinical teams 4) health plan by adhering to standardized workflows that support appropriate care planning and sharing program data with appropriate stakeholders.

Success in this position will depend greatly on exceptional communication skills, excellence in coordinating care and patient advocacy, and attention to detail.

Position Objectives:

The Clinical Transitions Nurse position is focused on coordinating UCM’s efforts to prevent avoidable hospital readmissions through optimal discharge disposition planning, patient education and coordination across the continuum of care. The Clinical Transitions Nurse will partner with the hospital and health plan to initiate UCM activities that are designed to support the patient, family/caregivers in a successful transition from hospital-to-home and appropriately referring patients into services to support ongoing wellness such as health plan and community medical groups internal care management programs. The Clinical Transitions Nurse is a patient advocate who will partner with patients to navigate the healthcare system and ensure that patients receive timely, high-quality care.

Summary of Responsibilities:

  1. Collaborates with hospital, health plan, and PCP discharge planning/transitions and evaluates patients’ appropriateness for program inclusion using patient identification protocol (verify patient meets clinical criteria).
  2. Verifies patient demographic information is correct; if indicated, amend to reflect updated information.
  3. Initiates face-to-face patient transition to begin identification of post-discharge needs and educates the patient/family/caregivers on the Readmission reduction program.
  4. Upon patient acceptance of services, CTN will initiate and complete CTN encounter intake documentation to ensure all patient needs are documented and met by the program. CTN will document initial care transition encounter note within 24hrs of patient referral/ acceptance and update as status of patient.
  5. Educates patient on the importance of the post-discharge program follow up appointment & involves the family caregivers in the educational process, assesses post-discharge educational coaching needs, and introduces patient family to the program; assures patient and family have program contact information
  6. Ensures that the patient/caregivers is educated on obtaining all necessary prescriptions prior to discharge from hospital and confirms patient's understanding of medication, pharmacy, and delivery method, in collaboration with hospital/health plan/PCP discharge planning
  7. Identifies primary care physician, specialists and case managers involved with patient’s plan of care; ensures transfer of needed clinical information to UCM
  8. Ensures demographic and clinical information is loaded into UCM electronic medical record
  9. CTN will document care transition and program intake in CTN encounter note within 24hrs of patient referral/UCM acceptance and update as status of patient transfer changes
  10. Ensures UCM virtual and in-person encounters are scheduled
  11. Post discharge, ensures patient has timely medical and/or psychiatric follow-up and ancillary support services necessary for recovery
  12. Provides clinical guidance to UCM Care Coordinators implementing follow-up clinical referrals; assists with communication of diagnostic testing results
  13. Ensures timely flow of UCM documentation and information is sent to primary care medical group, specialists, and case manager(s) and maintains contact with PCP practices
  14. Communicates with the internal team and continually analyzes best practices and opportunities to provide care to and reach any relevant and/or underserved population within our service area
  15. Adhere to all corporate Information Security policies and procedures.
  16. Identify any breaches or potential breaches of corporate Information Security standards and communicate those to appropriate individuals.
  17. Maintain integrity, availability, and confidentiality of all PHI.
  18. Adhere to HIPAA standards for information security, privacy, and confidentiality

Core Competencies:

  • Must have excellent verbal and written communication skills with patients/caregivers and all members of the healthcare team(s)
  • Must be proactive in rapidly establishing rapport and quickly becoming
  • Ability to work collaboratively with health care professionals at all levels to achieve established goals and improve quality outcomes.
  • Highly organized and ability to work autonomously and ability to complete competing priorities
  • Demonstrates a desire to promote a person-centered philosophy of care and seeks ways to facilitate helping more patients
  • Excellent critical-thinking, observation, problem-solving, and analytical skills
  • Ability to lead and motivate others to execute a plan in a rapidly changing environment
  • Knowledge of hospital discharge planning, post-acute care needs and case management
  • EHR proficient
  • Current clinical license
  • Valid driver's license and an insured vehicle in proper working order for local travel
  • Behavioral health experience a huge plus


  • Current, unrestricted nursing license in NYS (RN)
  • College degree, preferably a BSN

Physical Demands:

Occasional (0-40%) / Frequent (41-71%) / Constant (72%-100%)

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job.

  • Constant computer work which may require repetitive motion, prolonged periods of sitting and sustained visual and mental applications and demands.
  • Occasional lifting, bending, pulling, collating, and filing, some of which could be heavy (>10lbs)

Travel: Only local travel is anticipated for this position (no overnight stays, etc.)

Other Duties:

This job description is intended to convey information essential to understand the scope of the position. It is not intended to be an exhaustive list of skills, efforts, duties, or responsibilities associated with the position. Duties, responsibilities, and activities may change at any time with or without notice.

Equal Employment Opportunity Statement:

UCM Digital Health maintains a strong policy of equal opportunity in employment. It is out objective to recruit, hire, and retain the most qualified individuals without regard to race, color, religion, sex, sexual orientation, or identity, national origin, age, disability, veteran status or any other characteristic or status protected by applicable federal, state or local law. Our equal employment philosophy applies to all aspects of employment, including recruitment, compensation, benefits, training, promotions, transfers, job benefits, and termination.

UCM Digital Health is an at-will employer. We recognize that you retain the option, as does the company, of ending your employment with UCM Digital Health at any time, with or without notice and with or without cause.



  • Minimum 2 years’ experience in a hospital, primary care office or homecare setting
  • Hospital Discharge planning/case management
  • Hands-on experience as part of an interdisciplinary team (physicians, case managers, nurses, etc.)
  • Deep understanding of factors leading to high/over utilization of ER and inpatient admissions such as complex medical and behavioral health care needs and social determinants of health
  • Proven track record in teamwork, collaboration and driving excellence in patient care

Salary and Perks

$78k - $83k

About UCM Digital Health

UCM Digital Health (UCM) offers a digitally integrated, whole person health solution that provides patients with immediate access to care on their terms.

UCM combines a digital front door platform, multi-disciplinary team of providers, and a 24/7 telehealth triage, treatment, and navigation service to provide a range of patient services, including emergent and urgent care, primary and specialty care, behavioral health, and more. Care begins digitally and can seamlessly integrate across other points of care for a simple patient experience.

UCM brings together clinical expertise, advanced technology and compassionate care to offer powerful advantages for insurers, employers, patients and providers.

UCM Digital Health (UCM) offers a digitally integrated, whole person health solution that provides patients with immediate access to care on their terms.

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