The Transitional Care Nurse primary responsibilities include providing outreach to patients discharging from a higher level of care to home to ensure safe transition. They are also responsible for coordination of care, and providing linkage to internal resources and community services. This role will be focused on chronic care management, transition of care, coordination of care, and quality metrics. The Transitional Care Nurse will be expected to communicate and work in collaboration with our Chronic Care Management team, interdisciplinary team members within the organization and external community partners and contractual partners.
Successful candidate must demonstrate the Rural Health Group Core Competencies, which include:

1. Good Judgment
2. Communication/Customer Service/Teamwork
3. Passion
4. Honesty
5. Responsibility
6. Job-Specific Skill Set

Responsibilities:

• Use data to target patients for outreach, education, and intervention.
• Provides education on the appropriate level for patients and their support system
• Provides Transition of Care services to patients discharging from a higher level of care to home in order to reduce risk of complications and fragmented care.
• Conducts patient outreach for Medication Adherence care gaps
• Utilizes motivational interviewing techniques to measure a patient’s understanding and acceptance of the proposed plan and his/her willingness to change.
• Support quality initiatives within the organization
• Addresses the total patient and support systems (i.e. caregiver, family, etc.), inclusive of medical, psychosocial, behavioral, cultural and spiritual needs.
• Clearly and effectively communicates and coordinates with all providers, interdisciplinary team members, community resources, and contracted partners.
• Documents clearly, completely and concisely in electronic medical record related to all care management activities.
• Willingly performs other duties as assigned.

Requirements

• LPN or RN in the State of North Carolina with at least 2 years of clinical experience
• Certified – Basic Life Support/ CPR
• Excellent problem-solving skills
• Basic computer skills; must be able to quickly learn to use eClinicalWorks electronic health record system to accurately complete the required documentation in patients’ records. 
• Highly organized and ability to meet deadlines
• Attentive to detail, quality and accuracy
• Self-starter and able to work with minimal supervision
• Ability to interrelate with wide variety of people
• Ability to maintain high level of confidentiality
• For bilingual candidates: Language assessment required before an offer of employment can be made
• All offers of employment are contingent upon passing post-offer, pre-hire drug screen and successful completion of background check (requiring social security number, date of birth, and driver's license number)