Transitional Care RN – Improve Post-Discharge Outcomes

UNC Health Care; Hendersonville (NC); Hybrid; USD 70,000 - 95,000; Full time

Job summary

UNC Health Care is seeking a Care Manager - Care Transitions to support high-risk patients after hospital discharge. You will perform telephonic assessments, review medications, educate patients, and coordinate transitions to reduce readmissions. This role involves data tracking and presenting trends to the team.

The position requires NC RN licensure, BSN, BLS, and 3+ years clinical experience, including case management. Hybrid work arrangement and 40-hour weeks are typical.

Qualifications

• Must be licensed to practice as a Registered Nurse in North Carolina or a compact state.
• Three years of experience in a clinical capacity (acute care, home health, or long-term care).
• One year of experience as a Registered Nurse (RN).
• Excellent verbal and written communication skills.
• Cultural competency and/or experience with diverse populations.
• Current Basic Life Support (BLS) certification.
• Bachelor's of Science in Nursing (BSN).
• Experience in Case Management/Discharge Planning.
• Experience with community resources and agencies.
• Experience with data tracking, analysis, and reporting tools (e.g., spreadsheets and dashboards).

Responsibilities

• Identifies high-risk admissions and prioritizes transitional care if needed.
• Contacts patients post-discharge for telephonic assessments and medication review.
• Educates patients and caregivers on disease management and adherence.
• Coordinates referrals to community resources and support services.
• Monitors patient progress with follow-up and documents interventions.
• Analyzes readmission data to identify trends and contributing factors.
• Maintains readmission tracking tools and reporting dashboards.
• Conducts root-cause reviews of readmissions.
• Prepares readmission data and outcomes for leadership reviews.
• Collaborates with care team to translate findings into action.

Skills

RN license

Communication skills

Cultural competency

Case management

Data tracking & reporting

Education

BSN

Tools

Dashboards

Spreadsheets

Job description

UNC Health Care is seeking a Care Manager - Care Transitions to support high-risk patients after hospital discharge. You will perform telephonic assessments, review medications, educate patients, and coordinate transitions to reduce readmissions. This role involves data tracking and presenting trends to the team.

The position requires NC RN licensure, BSN, BLS, and 3+ years clinical experience, including case management. Hybrid work arrangement and 40-hour weeks are typical.