Transition of Care Nurse

3 days ago


Church Creek, Maryland, United States Uphams Corner Health Center Full time
Job Title: Transition of Care Registered Nurse

Uphams Corner Health Center is seeking a skilled Transition of Care Registered Nurse to join our team.

About the Role:

The Transition of Care RN will work with a diverse community health population to provide follow-up, education, and outreach to patients post-discharge. This role involves collating and maintaining a registry of patients, providing provider support services, and working collaboratively with other RNs and primary care providers to assist in the treatment plan for the episode/condition that brought about the visit and prevent future visits.

Key Responsibilities:
  • Conduct outreach to patients after Emergency Department (ED) discharge to follow up on their discharge plan and educate about appropriate ED use.
  • Review post-discharge plan, screen for social determinants of health, review medication reconciliation, advise on follow-up appointment(s), and assist patients in obtaining referrals, medications, or other services that may apply.
  • Assess potential barriers to medication adherence and advise accordingly, demonstrate adequate knowledge of condition(s), discharge instructions, and self-care, and address barriers to care (financial, transportation) and follow-up tests.
  • Work in collaboration with the Telephonic Triage nurse to prevent unnecessary ED visits, overutilization of ED visits, or hospital admissions.
  • Engage patients into the Upham's Community Care health services, reminding them of the health center's hours and educating them about the UCC Urgent Care Department and its hours of operation.
  • Communicate and collaborate with other health team providers, including PCPs, specialists, VNA, to facilitate a smooth transition of care.
  • Collate and maintain a registry of patients utilizing hospital Emergency Departments.
  • Work in collaboration with team structures in Primary Care to obtain same-day or next available appointment for patients as part of follow-up with patient post-ED discharge.
  • Deliver patient care and patient education in a manner that is appropriate to the patient's age, physical ability, educational level, and culture.
Requirements:
  • Licensed Registered Nurse (B.S.N. preferred) in Massachusetts.
  • Two years of nursing experience, preferably in an ambulatory care, emergency department, or community health setting.
  • Experience in a culturally diverse setting.
  • Bilingual language skills in English/Spanish, English/Portuguese/Cape Verdean Creole, or English/Vietnamese preferred.
What We Offer:

Uphams Corner Health Center offers a dynamic and supportive work environment, opportunities for professional growth and development, and a competitive compensation package.

We are an equal opportunity employer and welcome applications from diverse candidates.



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