Transition Care Nurse: Telephonic Care Coordinator

Medical University of South Carolina; Murrells Inlet (SC); Hybrid; USD 41,000 - 55,000; Full time

Job summary

The Transition Care Nurse (RN) promotes safe transitions across the care continuum by completing telephonic outreach to patients discharged from the hospital and ensuring timely follow up care within the primary care setting.

This position supports value-based care initiatives by ensuring the requirements for transitional care are completed, including thorough documentation, timely follow-up appointments with the patient's primary care provider, and prevention of unnecessary utilization of acute

Qualifications

• 2+ years’ clinical RN experience required.
• Experience in community health education, case management or primary care.
• Exemplary level of core customer service skills and the ability to work independently and manage changing priorities.

Responsibilities

• Assist with data metrics to measure impact.
• Serve as patient resource for information, education, and follow-up care coordination.
• Initiate documentation to complete the transitional care appointment with the primary care provider.
• Reinforce the discharge plan and importance of follow-up with the primary care provider.
• Conduct medication reconciliation and document in the electronic record system.
• Facilitate timely referrals to appropriate community resources and meet transitional care management timelines.

Skills

Clinical RN experience

Community health education

Case management

Primary care experience

Customer service

Education

Bachelor of Nursing degree preferred

Job description

The Transition Care Nurse (RN) promotes safe transitions across the care continuum by completing telephonic outreach to patients discharged from the hospital and ensuring timely follow up care within the primary care setting.

This position supports value-based care initiatives by ensuring the requirements for transitional care are completed, including thorough documentation, timely follow-up appointments with the patient's primary care provider, and prevention of unnecessary utilization of acute