Transitional Care Registered Nurse ( RN) - Family Medicine

Dartmouth-Hitchcock Health•New London, NH

About The Position

Under the direction of the Associate Director of Ambulatory Nursing, the Transitional Care Registered Nurse ensures safe and effective patient transitions across the care continuum, including hospitals, rehabilitation facilities, skilled nursing facilities, and home. As a patient educator and advocate, the nurse supports communication with patients and caregivers to promote effective transitions, improved self-management, reduced readmissions, and patient-centered care. The role supports both New London Medical Group and Newport Health Center.

Requirements

Graduate of an accredited School of Nursing.
Licensed RN with NH eligibility.

Nice To Haves

3 to 5 years of related experience, preferably in Ambulatory Nursing, Case Management, or Transitional Care Management.

Responsibilities

Develop and implement individualized transitional care plans addressing medical, social, psychosocial, and functional needs across care settings.
Educate patients and caregivers about diagnoses, treatment options, medication reconciliation, chronic disease symptom management, and community resources.
Advocate for patients by identifying barriers to care, coordinating services, and ensuring concerns are addressed through resolution.
Collaborate with physicians, case managers, pharmacists, social workers, rehabilitation staff, and community agencies to support safe, coordinated transitions.
Document patient encounters, transition plans, and required data elements accurately in electronic medical records and/or dashboards.
Participate in interdisciplinary meetings as the patient’s advocate to coordinate communication and align care goals across providers.
Identify transitional care workflow improvement opportunities and collaborate with leadership on program enhancements.
Establish and maintain positive working relationships with internal and external stakeholders to support care coordination.
Help patients develop self-management skills and improve quality of life through shared clinical decision-making.
Ensure patient and family needs are met when transitioning between care settings, emphasizing communication and collaboration.
Perform other duties as assigned to support departmental and organizational goals.