Transition Care RN: Post-Discharge Care Coordinator

Medical University of South Carolina; United States; On-site; USD 55,000 - 83,000; Full time

Job summary

The Transition Care Nurse (RN) at the Medical University of South Carolina delivers telephonic outreach to patients discharged from the hospital and ensures timely follow-up in primary care settings. This role supports value-based care by completing transitional care requirements, thorough documentation, and coordinating with primary care providers to prevent unnecessary acute care utilization.

Responsibilities include reviewing discharge reports, assigning cases by acuity, documenting call

Qualifications

• Bachelor's degree in nursing preferred.
• RN licensure by SC Board or a compact state is required.
• Current BLS certification as required.

Responsibilities

• Assist with data metrics to measure impact.
• Serve as patient resource for information, education, and follow-up care coordination.
• Initiate documentation from assessments to complete transitional care appointment.
• Reinforce discharge plan and follow-up importance with PCP.
• Conduct medication reconciliation and communicate discrepancies to the care team.
• Facilitate timely referrals to community resources per the plan of care.

Education

Bachelor of Nursing degree

RN license (SC or compact)

BLS certification

Job description

The Transition Care Nurse (RN) at the Medical University of South Carolina delivers telephonic outreach to patients discharged from the hospital and ensures timely follow-up in primary care settings. This role supports value-based care by completing transitional care requirements, thorough documentation, and coordinating with primary care providers to prevent unnecessary acute care utilization.

Responsibilities include reviewing discharge reports, assigning cases by acuity, documenting call