Transitional Care Nurse



Gastonia, NC, USA
Posted on Tuesday, August 8, 2023
Location: Kintegra Health- Corporate Gastonia
Position: Transitional Care Nurse
Summary of Position: The Transitional Care Nurse primary responsibilities include providing outreach to patients discharging from a higher level of care to home to ensure safe transition. They are also responsible for coordination of care, and providing linkage to internal resources and community services. This role will be focused on chronic care management, transition of care, coordination of care, and quality metrics. The Transitional Care Nurse will be expected to communicate and work in collaboration with our Chronic Care Management team, interdisciplinary team members within the organization and external community partners and contractual partners.
Required Skills: Excellent verbal communication skills. Must be able to work with changing priorities. Requires excellent organizational, problem solving and critical thinking skills. Must be able to interact with individuals of all cultures and levels of authority. Requires the ability to maintain confidentiality. Must be able to function as part of a team.
Preferred Skills: Motivational interviewing, knowledge of chronic diseases, ability to reconcile medications, and assessment of patients for priority outreach.
Education: LPN or RN with an unrestricted license to practice nursing in NC
Experience: Ambulatory or acute care setting, home health, or public health.
Certification(s): BLS/CPR
Kintegra Health is a is a community sponsored, family-centered provider of health care, health education and preventive care services without regard to the ability to pay. We screen potential employees to first ensure alignment with our core requirements followed by the requisite position skills set. In doing so we need staff committed to this mission who do their best to live and work the characteristics of our core values as we strive to care forever-increasing members of the communities we serve.
Our goals are:
 To provide continuing comprehensive and accessible primary care services to individuals and families of all economic levels within Gaston County.
 To provide primary care services to meet the physical as well as social health needs of individuals and families, promoting health maintenance, providing timely diagnostics, treatment and referral services.
 To emphasize preventive care through patient and community education to help individuals become aware and responsible for their own health behaviors.
 To employ an interdisciplinary team approach in collaboration with other community providers to provide a continuum of appropriate patient/family-oriented care in a cost-effective manner


  • LPN or RN in the State of North Carolina
  • Certified – Basic Life Support
  • Excellent problem-solving skills
  • Computer skills required, Electronic Health Record experience preferred
  • Highly organized and ability to meet deadlines
  • Attentive to detail, quality and accuracy
  • Self-starter and able to work with minimal supervision
  • Ability to interrelate with wide variety of people
  • Ability to maintain high level of confidentiality

Work Environment and Physical Demand Related to the Position:

  • Prolonged periods of sitting, reading and documentation are required.
  • Intact sight and hearing with or without assistive devices if required.
  • Frequent walking for short distances.
  • Repetitive motion work with keyboards; limited physical activity.
  • Personal vehicle travel to patient home, provider office, offsite meetings.

Key Responsibilities:

  • Use data to target patients for outreach, education, and intervention.
  • Provides education on the appropriate level for patients and their support system
  • Provides Transition of Care services to patients discharging from a higher level of care to home in order to reduce risk of complications and fragmented care.
  • Conducts patient outreach for Medication Adherence care gaps
  • Utilizes motivational interviewing techniques to measure a patient’s understanding and acceptance of the proposed plan and his/her willingness to change.
  • Support quality initiatives within the organization
  • Addresses the total patient and support systems (i.e. caregiver, family, etc.), inclusive of medical, psychosocial, behavioral, cultural and spiritual needs.
  • Clearly and effectively communicates and coordinates with all providers, interdisciplinary team members, community resources, and contracted partners.
  • Documents clearly, completely and concisely in electronic medical record related to all care management activities.
  • Willingly performs other duties as assigned.

Kintegra Health Core Requirements:

  • Patient First – An approach to care that holds primary, the well-being and desires of the patient
  • Build not Blame – Focusing first on finding fault with the process rather than the person
  • Integrity and Honesty – Fostering an acceptance of openness, honesty, and fairness in words, deeds and the use of organizational resources judiciously for both internal and external customers
  • Cooperation and Flexibility – Related to an internal believe that we function as part of an interdependent team with only shared gains or losses thereby committed to assisting whenever possible beyond the prerequisite job description
  • Culturally Sensitive – Always working toward increasing one’s ability to understand, communicate with, effectively interact and care for people across cultures, while having an acute awareness of one’s own culture.
Please note this position is posted on behalf of our partner practices. This individual will be working at the specific practice that is mentioned in the above details and will not be a direct employee of Aledade, Inc. so will therefore not be eligible for the benefits available to Aledade employees.