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Transitions of Care Nurse (RN), Primary Care

This job posting is no longer active.

Job ID: 115557
Location: Hendersonville, NC
Facility/Division: Pardee UNC Health Care
Status: Full Time
Shift: Day Job

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Job Description


Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve.


The Transitions of Care Nurse provides telephonic outreach to Pardee BlueMD patients that have been recently discharged from a hospital, emergency department or skilled nursing facility. The Transitions of Care Nurse conducts a telephonic assessment and ensures that the patient &/or family/caregiver has and understands their discharge treatment plan. The Transitions of Care Nurse provides support and education regarding the discharge treatment regimen, completes a medication review of any new/changed/discontinued medications, and ensures the patient has a follow-up appointment with the appropriate providers. The Transition of Care Nurse works to ensure the patient has a safe transition back to their home/community.


  • Assesses and navigates the electronic medical record system to obtain daily discharge list and patient medical record.

  • Reviews patient medical record for relevant details such as hospitalization record, discharge summary, medication changes, and discharge orders.

  • Contacts patients as part of routine outreach, making repeated attempts as warranted as per documented policy.

  • Performs a telephonic assessment and provides education and support regarding the discharge treatment plan to the patient and/or family/caregivers.

  • Identifies any potential gaps in care and makes referrals as appropriate.

  • Educates patients and their family/caregivers regarding disease processes, medication management, symptom exacerbation and appropriate site of care.

  • Identifies any available community resources and facilitates access to care and services when needed.

  • Works with practice support and scheduling staff to ensure patient has a primary care follow-up appointment scheduled within the defined timeframe.

  • Monitors patient for after discharge over multiple follow-up outreaches to the patient to assess status.

  • Documents all patient encounters in the electronic medical record per the defined workflow.

Other Information:



  • Must be licensed to practice as a Registered Nurse in the state of North Carolina or one of compact states by the day of clinical care.

  • Three (3) years of experience working in a clinical capacity in an acute care, home health, or long-term care setting.

  • One (1) year of experience working as a Registered Nurse (RN)

  • Active Driver’s License and access to transportation

  • Excellent verbal and written communication skills.

  • Cultural competency and/or experience working with individuals with a wide range of backgrounds

  • Current Basic Life Support (BLS) certification


  • Experience with community resources and agencies.

Job Details

Legal Employer: Pardee - HCHC

Entity: Pardee UNC Health Care

Organization Unit: Blue MD Administration

Work Type: Full Time

Standard Hours Per Week: 40.00

Work Assignment Type: Hybrid

Work Schedule: Day Job

Location of Job: DR PARK

Exempt From Overtime: Exempt: No

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Diversity Statement

UNC Health and the UNC School of Medicine are committed to valuing all people throughout our organization, regardless of background, lifestyle, and culture. A diverse and inclusive work environment for staff and culturally appropriate care for our patients, are essential to fulfilling our UNC Health vision of improving the health of all North Carolinians.

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