Job description
Job Description Summary
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.
Entity
MUSC Community Physicians (MCP)
Worker Type
Employee
Worker Sub-Type
Regular
Cost Center
CC005802 MCP - Population Health Transitional Care Management (TCM)
Pay Rate Type
Hourly
Pay Grade
Health-28
Scheduled Weekly Hours
40
Work Shift
Job Description
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.
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
Education Qualifications
• ADN Required Experience Qualifications
• 2 or more years’ experience as a clinical RN Required
• Prior experience in community health education, case management or primary care
• Preferred Prior experience as a Health Educator Preferred Skills and Abilities
• Exemplary level of core customer service skills and competency Ability to work independently, adjust priorities often and establish rapport quickly
Additional Job Description
Bachelor’s degree in nursing required and three years related nursing experience. Licensure as a registered nurse by the South Carolina Board of Nursing or a compact state. Some positions require certification as a generalist in a related specialty area by the American Nurses Association (ANA). Current American Heart Association (AHA) Basic Life Support (BLS) certification or American Red Cross BLS for Healthcare Providers certification is required. *Population Health remote BLS not required.
