Transitional Care Registered Nurse ( RN) - Family Medicine

Overview

Under the direction of the Associate Director of Ambulatory Nursing, this role serves to ensure safe and effective patient transitions across the patient care continuum, to include the hospital, rehabilitation facilities, skilled nursing facilities, and home. As a patient educator and advocate, this position helps improve communication with patients and caregivers, resulting in effective care transitions, improved self-management skills, and reduced readmission rates while ensuring patient-centered care. This role will support both New London Medical Group and Newport Health Center.

Responsibilities

• Transitional Care Responsibilities
• Develop and implement individualized transitional care plans that address medical, social, psychosocial, and functional needs, ensuring continuity of care across all settings.
• Provide patient and caregiver education regarding diagnosis, treatment options, medication reconciliation, chronic disease symptom management, and available community resources.
• Serve as a patient advocate by identifying barriers to care, coordinating needed services, and ensuring concerns are addressed until resolution.
• Collaborate with interdisciplinary teams - including physicians, case managers, pharmacists, social workers, rehab staff, and community agencies to ensure unified, safe, and effective transitions.
• Maintain accurate documentation of patient encounters, transition plans, and required data elements in electronic medical records and/or dashboards.
• Participate in interdisciplinary meetings as the patient’s advocate, ensuring coordinated communication and alignment of care goals across providers.
• Identify opportunities for process improvement within transitional care workflows and collaborate with leadership to implement program enhancements.
• Establish and maintain positive working relationships with internal and external stakeholders to support seamless care coordination.
• Assist the patient with developing skills for improved self-management of their care and improved quality of life using shared clinical decision making.
• Responsible for assuring the patient and family needs are met when transitioning from one care setting to another, with an emphasis on improving communication and collaboration.
• Perform other duties as assigned to support departmental and organizational goals.

Qualifications

• Graduate of an accredited School of Nursing
• 3 to 5 years related experience preferred (Ambulatory Nursing, Case Management, Transitional Care Management Experience)

Required Licensure/Certifications

REQUIRED LICENSE(S)

• Licensed RN with NH eligibility