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.

What you will do:

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.

Physical Requirements:

1. Ability to stand or sit for extended periods of time.
2. Proficiency in manual dexterity and fine motor skills for tasks such as taking patient vitals, administering injections, or conducting physical exams.
3. Capacity to lift and move patients or medical equipment as needed.
4. Visual acuity and color perception to accurately read medical charts, documents, and monitors.
5. Auditory ability to effectively communicate with patients and colleagues, as well as to perceive important sounds such as alarms or patient instructions.
6. Stamina and resilience to handle the physical and emotional demands of providing patient care, including long shifts and potentially stressful situations.
7. Mobility to navigate clinical environments, including moving between patient rooms, offices, and other areas of the facility.
8. Compliance with infection control protocols and proper use of personal protective equipment to maintain a safe and healthy work environment.

If you like working with energetic enthusiastic individuals, you will enjoy your career with us!

The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.

Medical University of South Carolina participates in the federal E-Verify program to confirm the identity and employment authorization of all newly hired employees. For further information about the E-Verify program, please click here: http://www.uscis.gov/e-verify/employees