Transitional Care Nurse

Jobtailor; Beverly (MA); On-site; USD 85,000 - 115,000; Full time

Job summary

Jobtailor in Beverly, MA seeks a dedicated RN care coordinator to manage discharge-focused, high-risk patient plans. You will perform telephonic assessments, reconcile medications, and coordinate with primary and specialty care teams to follow through on discharge instructions, with emphasis on patient education and engagement.

The role requires RN (BSN preferred), BLS, and experience with EHR/documentation, in a fast-paced team.

Qualifications

• Graduate from an accredited Nursing Program required.
• Bachelor's degree in Nursing preferred.
• License Registered Nurse preferred.
• American Heart Association – Basic Life Support Certificate required.
• Licensed Practical Nurse (LPN) 3-5 years related work experience required.
• Detail oriented with the ability to work in a fast paced, high call volume team environment.
• Advanced skills with Microsoft applications which may include Outlook, Word, Excel, PowerPoint or Access and other web-based applications.
• May produce complex documents, perform analysis and maintain databases.
• Advanced understanding of computer skills - email, typing, accessing work systems.

Responsibilities

• Provide patient-centered coordination of care management to medically complex, high-risk patients after discharge.
• Perform telephonic patient assessment to establish health status and barriers to discharge plan.
• Complete discharge medication reconciliation and document encounters in the medical record.
• Review discharge instructions and coordinate follow-up labs and appointments.
• Provide health coaching and education on discharge plan of care.
• Encourage self-engagement to achieve goals and adherence.
• Document encounter summaries in the patient’s EHR per BIDHC protocols.
• Identify clinical issues and notify appropriate providers and staff.
• Collaborate with the care team to ensure all aspects of the plan are met.

Skills

Patient-centered care coordination

Telephonic patient assessment

Medication reconciliation

EHR documentation

Health coaching

Detail oriented

Team collaboration

Self-engagement

Education

Graduate from accredited Nursing Program

Bachelor's degree in Nursing preferred

Tools

Microsoft Outlook

Microsoft Word

Microsoft Excel

Microsoft PowerPoint

Web-Based Applications

Job description

• Provide patient-centered coordination of care management to medically complex, high-risk patients who have been discharged from an acute or sub-acute inpatient facility.
• Perform telephonic patient assessment with information obtained from discharge summary and patient/caregiver to establish patient health status, identify early health issues and potential barriers of the discharge plan of care.
• Complete discharge medication reconciliation, identify discrepancies or adherence barriers and accurately document the encounter in the medical record.
• Review discharge summary instructions and provide care coordination, follow up lab and diagnostic studies, specialty and primary care provider appointments.
• Provide health coaching and education to patient/caregiver on discharge summary plan of care.
• Encourage self-engagement with a focus on achievement of goals and identifies barriers to adherence.
• Document summary of the patient/caregiver encounter in patient's EHR according to BIDHC protocols.
• Identifies clinical issues and lapses in standards of care and notifies appropriate provider and staff.
• Collaborates with provider or other practice team members to ensure all aspects of patient's plan of care has been met.

Requirements

• Graduate from an accredited Nursing Program required.
• Bachelor's degree in Nursing preferred.
• License Registered Nurse preferred.
• American Heart Association – Basic Life Support Certificate required.
• Licensed Practical Nurse (LPN) 3-5 years related work experience required.
• Detail oriented with the ability to work in a fast paced, high call volume team environment.
• Advanced skills with Microsoft applications which may include Outlook, Word, Excel, PowerPoint or Access and other web-based applications.
• May produce complex documents, perform analysis and maintain databases.
• Advanced understanding of computer skills - email, typing, accessing work systems.

Core Competencies

Demonstrates expertise in patient-centered care coordination for high-risk patients, including telephonic assessments, medication reconciliation, and health coaching. Proficient in documenting encounters in EHR systems and collaborating with healthcare teams to ensure comprehensive care delivery.

Highest-signal resume keywords

• Patient-Centered Care Coordination
• Telephonic Patient Assessment
• Medication Reconciliation
• EHR Documentation
• Health Coaching

ATS Optimization Keywords

Hard Skills

• Patient Assessment
• Medication Reconciliation
• Care Coordination
• Clinical Issue Identification
• Health Education

Soft Skills

• Detail Oriented
• Team Collaboration
• Self-Engagement Encouragement

Certifications & Qualifications

• Registered Nurse License
• Basic Life Support Certificate

Industry Keywords

• Patient Care Management
• Discharge Planning
• High-Risk Patient Care
• Caregiver Education
• Healthcare Collaboration

Tools & Technologies

• Microsoft Outlook
• Microsoft Word
• Microsoft Excel
• Microsoft PowerPoint
• Web-Based Applications