The Transitional Care Nurse works as a part of the interdisciplinary team, as well as with community agencies, to ensure post-discharge collaboration in meeting patient's needs as determined by the social determinants of health screening. The TCN ensures that comprehensive care in the community is available for the patient in the post-hospital discharge period, with the goal of preventing readmission. Union: NYSNA Grant Funded, 1115 Waiver Monday- Friday 9am-5PM Requirements: • Current RN licensure in New York State • Bilingual ( English & Spanish ) • 2 years of Med-Surg, ED & Community Health experience required. • BSN required • MSN preferred • BLS & ACLS