Foundation Medical Partners - RN Care Transition Specialist - Acute Care Clinic - Full Time

Come work at the best place to give and receive care!

Job Description : Who We Are :

Affiliated with Southern New Hampshire Medical Center, Foundation Medical Partners is the second largest multi-specialty group in New Hampshire and serves the greater Nashua community. We encourage the professional growth and development of our employees and are proud of the workplace culture we have developed.

About the Job :

The RN Care Transition Specialist is responsible for managing care for recently discharged hospitalized patients promoting effective education and self-management support. The incumbent will work closely with providers and community resources to manage ambulatory patient's health care needs, treatment goals, and transitions between care settings.

What You'll Do :

• Provide chronic disease self-management support and education to patients. Educate patient on self-management activities, medications, nutrition, and activate patient toward self-management goals to improve clinical outcomes.
• Provide Care Coordination across settings and transitions of care including discharge from acute and sub-acute care, specialty referrals, and pre-visit planning.
• Act as liaison to partners within the health-system and community to enhance relationships and the development and maintenance of patient-centered care coordination and referral procedures.
• Manage transition-of-care and facilitate follow-up after discharge from inpatient hospitalized patients, including pre-visit planning and post-discharge follow-up.

Who You Are :

Why You'll Love Us :

So much more!

Work Shift :

Monday- Friday : 8 AM - 5 PM

SolutionHealth is an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, disability status, veteran status, or any other characteristic protected by law.