Transition Care Nurse: Care Coordination & Follow-Up

Medical University of South Carolina; Northern (KY); Ibrido; USD 39.000 - 50.000; Tempo pieno

Descrizione del lavoro

The Medical University of South Carolina is seeking a Transition Care Nurse (RN) to support safe patient transitions from hospital to primary care via telephone outreach and timely follow-up. The role emphasizes documentation, coordination with PCPs, and preventing unnecessary ED visits during discharge.

Responsibilities include data metrics, medication reconciliation, and ensuring adherence to transitional care management timelines, with a focus on high-quality patient education and resource

Competenze

• ADN required and RN license.
• 2+ years' experience as a clinical RN.
• Experience in community health education, case management or primary care.
• Preferred: Health Educator experience.
• Excellent customer service and ability to work independently, adjust priorities often and establish rapport quickly.

Mansioni

• Assist with data metrics to measure impact.
• Serve as patient resource for information, education, and follow-up care coordination during transitional period; support team in higher acuity transitions.
• Initiate documentation to complete transitional care appointments with the primary care provider.
• Reinforce discharge plan and importance of follow-up with PCP.
• Conduct medication reconciliation and communicate discrepancies to the primary care team; document using electronic records.
• Facilitate timely referrals to community resources and adhere to transitional care management timelines.

Conoscenze

Customer service

Independence

Prioritization

Rapport building

Formazione

ADN Required

RN experience 2+ years

Community health education / case management / primary care

Descrizione del lavoro

The Medical University of South Carolina is seeking a Transition Care Nurse (RN) to support safe patient transitions from hospital to primary care via telephone outreach and timely follow-up. The role emphasizes documentation, coordination with PCPs, and preventing unnecessary ED visits during discharge.

Responsibilities include data metrics, medication reconciliation, and ensuring adherence to transitional care management timelines, with a focus on high-quality patient education and resource