New

Transitions of Care Nurse (RN), Primary Care

UNC Health Care
United States, North Carolina, Hendersonville
May 15, 2025
Job Description Description Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve. 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: 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: 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 Preferred 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