Transitional Care RN: Patient Advocate & Care Navigator

Dartmouth-Hitchcock Health; New London (NH); On-site; USD 70,000 - 90,000; Full time

Job summary

Dartmouth-Hitchcock Health's ambulatory nursing team in New London/Newport seeks an RN to coordinate safe patient transitions across hospital, rehab, SNF, and home. Under supervision of Associate Director, you will educate patients and families and advocate for timely, coordinated care.

Responsibilities include developing individualized transitional care plans, medication reconciliation, care coordination with interdisciplinary teams, documentation in EMR, and identifying opportunities for

Qualifications

• Graduate of an accredited School of Nursing
• 3 to 5 years related experience preferred (Ambulatory Nursing, Case Management, Transitional Care Management Experience)

Responsibilities

• Develop and implement individualized transitional care plans that address medical, social, psychosocial, and functional needs, ensuring continuity of care across all settings.
• Provide patient and caregiver education regarding diagnosis, treatment options, medication reconciliation, chronic disease symptom management, and available community resources.
• Serve as a patient advocate by identifying barriers to care, coordinating needed services, and ensuring concerns are addressed until resolution.
• Collaborate with interdisciplinary teams—including physicians, case managers, pharmacists, social workers, rehab staff, and community agencies to ensure unified, safe, and effective transitions.
• Maintain accurate documentation of patient encounters, transition plans, and required data elements in electronic medical records and/or dashboards.
• Participate in interdisciplinary meetings as the patient’s advocate, ensuring coordinated communication and alignment of care goals across providers.
• Identify opportunities for process improvement within transitional care workflows and collaborate with leadership to implement program enhancements.
• Establish and maintain positive working relationships with internal and external stakeholders to support seamless care coordination.
• Assist the patient with developing skills for improved self-management of their care and improved quality of life using shared clinical decision making.
• Responsible for assuring the patient and family needs are met when transitioning from one care setting to another, with an emphasis on improving communication and collaboration.
• Perform other duties as assigned to support departmental and organizational goals.

Job description

Dartmouth-Hitchcock Health's ambulatory nursing team in New London/Newport seeks an RN to coordinate safe patient transitions across hospital, rehab, SNF, and home. Under supervision of Associate Director, you will educate patients and families and advocate for timely, coordinated care.

Responsibilities include developing individualized transitional care plans, medication reconciliation, care coordination with interdisciplinary teams, documentation in EMR, and identifying opportunities for