Transitional Care Registered Nurse ( RN) - Family Medicine

Dartmouth 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. Serving as a patient educator and advocate, the nurse improves communication with patients and caregivers to support effective transitions, strengthen self-management, reduce readmissions, and provide patient-centered care. The role supports New London Medical Group and Newport Health Center.

Requirements

Graduate of an accredited School of Nursing.
Licensed Registered Nurse (RN) with New Hampshire eligibility.

Nice To Haves

Three to five years of related experience preferred, such as 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 following concerns through resolution.
Collaborate with physicians, case managers, pharmacists, social workers, rehabilitation staff, community agencies, and other interdisciplinary team members to support safe transitions.
Document patient encounters, transition plans, and required data accurately in electronic medical records and/or dashboards.
Participate in interdisciplinary meetings as the patient’s advocate to support coordinated communication and alignment of care goals.
Identify opportunities to improve transitional care workflows and collaborate with leadership on program enhancements.
Build and maintain positive relationships with internal and external stakeholders to support care coordination.
Help patients develop skills for improved self-management and quality of life using shared clinical decision-making.
Ensure patient and family needs are met during transitions between care settings, emphasizing communication and collaboration.
Perform other duties as assigned to support departmental and organizational goals.