Transitions of Care LPN

Job description

UConn Health Community Network Medical Group, Inc. seeks a 20‑hour per week Transitions of Care LPN in the Administration – Medical Group department. The nurse will review discharge documentation in the EMR, contact patients after hospital or skilled‑nursing‑facility stays, clarify care plans, and ensure information needed for Transitional Care Management (TCM) appointments is complete and accurate.
• Review daily discharge summaries and EMR documentation for Internal Medicine patients.
• Conduct outreach phone calls within 48 hours of discharge.
• Clarify hospital events, medication changes, and follow‑up instructions with patients and caregivers.
• Document call outcomes and any identified gaps in care in the EMR.
• Coordinate with providers to schedule TCM appointments as needed.
• Educate patients on post‑discharge self‑management and red‑flag symptoms.
• Communicate pertinent information to the care team to facilitate continuity of care.
• Track and report key metrics such as call completion rates and TCM billing eligibility.
• Maintain compliance with HIPAA and UConn Health policies during all communications.
• Participate in quality improvement initiatives related to transitional care.
• Active Licensed Practical Nurse (LPN) license in Connecticut.
• Minimum 1 year of clinical nursing experience, preferably in acute care, SNF, or case management.
• Strong verbal and written communication skills.
• Proficiency with electronic medical records (Epic preferred).
• Ability to work independently and manage a 20‑hour weekly schedule.
• Knowledge of Transitional Care Management (TCM) billing requirements.
• Excellent organizational and time‑management abilities.
• Demonstrated empathy and patient‑centered approach.
• Basic computer skills (Microsoft Office, email, phone systems).
• Commitment to maintaining confidentiality and adhering to regulatory standards.