Transitional Care Nurse (Tidelands)

Medical University of South Carolina

2d•Onsite

About The Position

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. This includes thorough documentation, timely follow-up appointments with the patient's primary care provider, and prevention of unnecessary utilization of acute care services during the discharge period. The nurse will access and review discharge reports, assign cases to the team based on acuity level, document the call summary, and identify priorities that need to be communicated to the provider for further intervention.

Requirements

ADN Required
2 or more years’ experience as a clinical RN Required
Prior experience in community health education, case management or primary care
Minimum of one year of work experience as a registered nurse required.
Licensure as a registered nurse by the South Carolina Board of Nursing or a compact state.
Current American Heart Association (AHA) Basic Life Support (BLS) certification or American Red Cross BLS for Healthcare Providers certification is required.

Nice To Haves

Prior experience as a Health Educator Preferred
Bachelor of Nursing degree preferred.
RN staff hired on or after July 1, 2013 with an Associate or Diploma degree in nursing are required to be enrolled in an accredited BSN program within two years and successfully obtain a BSN degree within four years of the RN hire or reclassification date.

Responsibilities

Assist with the compilation of data metrics to measure impact.
Serve as the patient resource for information, education, and follow-up care coordination during the transitional period.
Serve as a resource within the team to help manage higher acuity patient transitions.
Take the information from all assessments to initiate documentation that will result in the completion of 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 to identify any discrepancies and communicate to the primary care team.
Complete thorough, timely documentation utilizing identified electronic record software.
Facilitate timely referrals to appropriate community resources in accordance with the plan of care.
Adheres to timelines to meet transitional care management requirements.