ABOUT THE ROLE 

As a Transitions of Care RN, you will lead an important function of the organization and care delivery model. This role will be responsible for ensuring a smooth transition from a hospital or post-acute setting to home. You will work with a diverse team including, but not limited to physicians, APPs, clinic care managers, community health workers, social workers, and others, to build long-lasting and trusting relationships with our patients and the broader healthcare ecosystems. This role is based in the Asheville area and will require travel around Western North Carolina.

WHAT YOU’LL DO

Specific responsibilities for this role will include, but are not limited to:

• Manage the inbound notifications feed related to transitions of care events
• Support the technology and population health team to ensure accurate and timely notifications of admissions, discharges, and transfer events
• Travel to local hospitals to round on any admitted Hopscotch Primary Care patients
• Conduct outreach to patients following discharge to ensure discharge instructions are reviewed and post-discharge visit is scheduled
• Request discharge instructions from hospital or post-acute facility and ensure they are prepped for the post-discharge visit
• Conduct post-discharge medication reconciliation via telephone, in-person, or in-clinic
• Using shared decision making with patients, create and monitor care plans during the transitions of care period to prevent readmissions
• Ensures a smooth handoff from the transitions of care team to the clinic team
• Partner with the Clinic Care Manager RNs on preventative care to support ED diversion and decrease hospitalizations
• Other clinical duties as assigned

ABOUT YOU

You would be a great fit for this position if you have a minimum of 5 years of experience as RN embedded into an interdisciplinary team and the following:

• Active registered nurse (RN) license in North Carolina
• BLS certification
• Experience working in transitions of care or care management
• Demonstrated ability to work closely with an interdisciplinary team with multiple providers
• Clinical expertise in creating care plans during transitions of care
• Knowledge of clinical guidelines and workflows for ED diversion, as well as decreasing admissions and readmissions
• A problem-solving orientation and a flexible and positive attitude
• Experience utilizing electronic medical record systems
• Knowledge of community resources and resource navigation
• Experience with motivational interviewing, behavior change, health promotion, and coaching 
• Strong verbal and written communication skills and customer service orientation 
• Accomplished problem-solving skills and a highly flexible and accountable work ethic 
• Willingness for daily travel within Western North Carolina
• US work authorization 

From a cultural perspective, you are:

• Agile, yet thoughtful and can work effectively in a fast-paced, ever-changing environment
• Constantly seeking ways to simplify and improve how things are done, bringing a positive attitude to challenges
• Accountable, holding yourself and others to a high standard and seek to support and develop others
• Willing to roll up your sleeves to support the work required and collaborate effectively with people of all backgrounds
• Concise and articulate, drive towards clarity and deliver on your commitments
• Collaborative, assuming positive intentions
• Customer-focused, with a passion for serving patients and providers who make healthcare possible