Acute Care Transition Coordinator (RN)

About the role

Pinehurst Medical Clinic (PMC) is a recognized healthcare provider serving Moore County, Lee County, Cumberland County, Chatham County, and the surrounding six counties. Locally owned and managed, PMC offers a broad range of primary and specialty care services with a commitment to patient-centered, physician-led care that integrates the latest advances in medical technology. This position is located within the hospital emergency department.

Responsibilities

• Act as a change agent for innovative healthcare approaches, advocating for patient needs and follow-up through PMC and Evergreen Senior Care initiatives.
• Serve as a steward for customer relationships across partnering hospitals.
• Assist patients as an advocate and navigator through the healthcare system.
• Proactively address gaps in patient care identified through provider referrals, practice liaisons, hospital discharge planners, emergency room teams, electronic health records, and other multidisciplinary teams.
• Perform chart reviews and collaborate with the emergency department team to provide insights on patients’ overall health and diagnostic data.
• Collaborate with emergency department physicians and the PMC care team to formulate alternative dispositions for patients, facilitating outpatient testing and follow-up.
• Complete assessments for assigned patients, identify care gaps, develop goals, facilitate interventions, and create sustainable patient-centered action plans.
• Engage with community resources to support patients’ psychosocial, financial, and functional needs in a timely and cost-effective manner.
• Increase patient adherence to treatment plans through direct involvement or coordination of care and referrals to appropriate care management teams.
• Foster direct communication among all partners on the patient’s care team to optimize outcomes.
• Communicate consistently with the outpatient care team using phone calls, secure messaging, and outpatient EHR.
• Facilitate provider contact and care team appointments to coordinate patient care needs across the continuum of care.
• Other duties as assigned.

Requirements

• Licensed as a Registered Nurse or Practical Nurse in the State of North Carolina.

Preferred Qualifications

• One to two years of experience in a medical office setting.

Benefits

PMC supports the total health and well-being of team members with a comprehensive benefits package covering health, well-being, family, and future.

Schedule

• Day Shift (Monday through Friday).
• No weekends or holidays.

Pay

• Hourly (Non-Exempt).