Transitional Care RN

Rockville, MD
May 29, 2018
Jun 21, 2018
Full Time
AdvertisementAdventist Healthcare

The Transitional Care RN collaborates with the patient, physician, case manager, and other healthcare providers to facilitate patient access to healthcare and social services that enhance the patients health and well-being and his/her ability to adhere to the prescribed medical treatment regimen in the most efficient and cost effective manner possible.

The Transitional Care RN provides services to the client in a variety of community and clinical settings. This role works with a multidisciplinary team to identify patients in the hospital at increased risk for readmission and provide care coordination services in the outpatient setting by working with community providers and partners as well as the patients family. This role works in conjunction with the Care Transitions and Management Department team to expand access to outpatient services and to support its mission of reducing readmissions by improving transitions of care.

The Transitional Care RN also helps guide and deliver non-medical interventions, community health education, and navigation, in partnership with Community Health Workers and other community partners.


1. Assess, plan, implement, coordinate, monitor and evaluate healthcare services to meet an individual patient's specific health care needs in a cost-effective manner.

2. Coordinate patient care with patient, family, staff, physicians, and ancillary/community services to promote quality and cost efficient care.

3. Use the nursing process to provide outpatient care management services to an assigned caseload.

4. Act as a client advocate for the development of community resources and function as a liaison to external agencies relaying information to others which may impact care and/or services to patients.

5. Collaborate with regional hospitals and identify vulnerable high risk ED and inpatients. Educate hospital team members and patients about available network services.

6. Provide at least one home visit to each patient within 24-72 hours of discharge. Home visits will focus on medication reconciliation, disease education for patient and family, home safety checks (e.g., check for fall risks), and preparation for follow-up appointments with provider, among other things. This role will follow patients for approximately 90 days post-discharge from the hospital.


*Bachelors degree in nursing

*Current MD RN licensure

*3-5 years of experience in an acute care setting

*Strong assessment skills

*Ability to prioritize multiple tasks

*Ability to interact with various members of the health care team

*Ability to advocate for the patient/family

*Must be licensed and able to operate a motor vehicle as well as maintain automobile insurance and abide by requirements listed in AHC's Automobile/Fleet Management policy

*Good verbal and written communication skills

*Computer proficiency in e-mail, Microsoft suite application (Excel, Word, Outlook), windows environment, and the Internet

*At least one year of prior experience as a nurse case manager or discharge planner in the acute care setting desirable

*Evidence of a high level of skill in assessment, identification of problems, care planning, identification and development of community resources and patient/family teaching required.

*Ability to work effectively with others to accomplish organizational goals and to identify and resolve problems.

After finishing your online application, you will receive an e-mail to complete the Pegged Screening assessment. This screening is required of all RN applicants and must be completed before your resume can be forwarded to the manager.

Work Schedule

Full-time, benefits eligible

Shift: Day

Work Schedule

This is a full time position working Monday-Friday day shift. Benefits eligible

Tobacco Statement

Tobacco use is a well-recognized preventable cause of death in the United States and an important public health issue. In order to promote and maintain a healthy work environment, We will not hire applicants for employment who either state that they are nicotine users or who test positive for nicotine use.

We will withdraw offers of employment to applicants who test positive for Cotinine (nicotine). Those testing positive for cotinine are given the opportunity to re-apply in 90 days, if they can truthfully attest that they have not used any nicotine products in the past ninety (90) days and successfully pass follow-up testing.

Equal Employment Opportunity

We are an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected veteran status.

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