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The Care Transitions Clinical Coordinator [CTCC] is responsible for managing all transitional care activities for patients defined in his/her caseload. S/he ensures a timely transition along the care continuum. She/he is an active member of the interdisciplinary team with responsibility for assessing, planning, implementing and evaluating the care management of a select group of patients as well as providing input, through the interdisciplinary team planning process, into the care management planning for all assigned patients.

The CTCC is a registered professional nurse who completes PRIs for designated patient care units; and performs screens for those patients who are targeted as high utilizers with identified care needs. The CTCC formulates care plans in collaboration with patients/caregivers, other members of the IDT and payers that are in accordance with patient need and within regulatory and benefit coverage parameters. S/he helps determine and coordinate comprehensive care plans maximizing access to health plan benefits and community resources appropriate for the health care needs of the individual patient.


The CTCC must be PRI certified with proof of certification. Daily work schedule 8:30am- 5pm - 5-day work week, The CTCC should expect to work 1 weekend per month. NY State RN License, BSN degree preferred with 5 years of clinical nursing experience.


Department: Social Services Bargaining Unit: NYSNA Campus: MOSES  Employment Status: Regular Full-Time Address: 111 East 210th Street, BronxShift: Day Scheduled Hours: 8:30 AM-5 PM Req ID: 130472 


Montefiore is an equal employment opportunity employer. Montefiore will recruit, hire, train, transfer, promote, layoff and discharge associates in all job classifications without regard to their race, color, religion, creed, national origin, alienage or citizenship status, age, gender, actual or presumed disability, history of disability, sexual orientation, gender identity, gender expression, genetic predisposition or carrier status, pregnancy, military status, marital status, or partnership status, or any other characteristic protected by law. 



To heal, to teach, to discover and to advance the health of the communities we serve.

To be a premier academic medical center that transforms health and enriches lives.

Define our philosophy of care, they shape our actions and motivate and inspire us to pursue excellence and achieve the goals we have set forth for the future. Our values include:

  • Humanity
  • Innovation
  • Teamwork
  • Diversity
  • Equity