Transitions of Care Nurse (RN), Primary Care

Job Description

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.

Summary:
JOB SUMMARY

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.

Responsibilities:
RESPONSIBILITIES AND SCOPE

• 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:

QUALIFICATIONS

Required

• 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