RN - Transition of Care Nurse

Nursing ServicesCare Transition Dalton, Georgia


Hamilton Health Care System, Inc.

Job Description and Performance Standards


Title: Transition of Care Nurse  55477-2415

Department:  Care Transition

Reports To:  Director of Quality and CMO

Shift: 8:00am - 5:00pm / Monday - Friday

Shift: Full-Time



The Transition of Care nurse is responsible and accountable for ensuring high value patient care that is coordinated, efficient and aligned with institutional clinical and financial objectives. In collaboration with the healthcare team, the care nurse utilizes evidence-based practice to ensure that appropriate medical services are delivered to the patient in efforts to enhance the patient experience and improve overall patient satisfaction. The nurse will also coordinate services to optimize patient clinical outcomes and aid in disease management of high-risk patients. Also, he/she will work closely with other departments to reduce readmissions and unnecessary emergency department visits. The care nurse will also oversee the department goal to improve patient medication compliance. He/she will be required to organize and coordinate multidisciplinary teams involving pharmacy, IT, nursing, post discharge facilities, physicians (both hospital and private) and case management to optimize our quality of care and the patients' experience as they transition from admission to post discharge follow up appointments. The manager will need to utilize data to monitor progress and effectively communicate results to administration and department directors/managers. Additionally, the care nurse will be responsible for maintaining costs within the department budget, development of action/business plans specific to a service, quality initiative, or nursing unit, and development of proposals for innovative services that improve the quality of patient care. This position seeks a highly motivated self-starter with exceptional communication skills who wishes to build productive relationships with healthcare providers.


Education: Required Associate Degree in Nursing.  Bachelor’s and/or Master’s Degree in nursing preferred.

Licensure: Current Georgia RN License

Experience: Minimum of 3 years experience in Nursing or Case Management in an acute hospital setting required.  Proficiency in MS Office is required. Prior managerial experience preferred.  Prior experience in caring for chronic disease patients or other Care Coordinator experience preferred.  Certification in Lean six Sigma preferred. 

Skills and Core Competencies:

  • Dedicated to Professionalism, Respect, Integrity, Diligence and Excellence (P.R.I.D.E.) Values.
  • A self-motivated, detail, deadline, and service-oriented individual that can accurately set priorities, possesses precise written and verbal communication and excellent interpersonal skills.
  • Excellent problem solving and critical thinking skills. Strong management and leadership skills required.
  • Skilled in the art of human relations, problem solving and conflict resolution/negotiation.
  • Facilitates communication between hospital and medical staff.
  • Capable of facilitating learning of others and able to express oneself effectively before groups.
  • Demonstrates good role model qualities; ability to effectively interpret, implement and support approved hospital policies, philosophy and objectives.
  • Is self directed in maintaining and improving own competence in clinical skills as well as cognitive aspects of medical/surgical nursing practice, nursing theory, current research and disease management.
  • Capable of effecting positive change across all departments and with medical staff to improve the quality of patient care and the cost of services.
  • Intervenes as necessary with all healthcare professionals to assure quality and cost-effective care.
  • Ability to develop and maintain quality relationships with medical staff, ancillary staff and work as partners to facilitate organizational and community relationships.
  • Performs duties without direct supervision by conducting self in a professional, autonomous manner.
  • Working knowledge of Microsoft Office (especially Excel and PPT) and data bases used by Hamilton for clinical data collection and reporting.
  • Troubleshooting skills in the formulation of data reporting and interpretation of accreditation guidelines and standards.



Position involves extensive standing, walking, and reaching.  Frequent sitting, grasping, manipulation of equipment, and utilization of fine finger movements.  Occasional kneeling, crouching, squatting, twisting, and climbing.  Frequent patient positioning, involves patient transfers with use of slippery boards and transfers mats.  Involves understanding written and oral instruction, reading and understanding written material, basic math skills.  Ability to conceptualize, think abstractly and continuously.