RN Transitional Care Nurse-Cerebrovascular Program

Job Description Summary

The Transitional Care Nurse (TCN) in the Outpatient Cerebrovascular Program reports directly to the Stroke Program Director and works collaboratively with the Comprehensive Cerebrovascular Medical Director and Stroke Clinic Nurse Practitioner(s). This role is essential in providing transitional care to stroke patients and their families, ensuring care continuity from acute hospitalization to rehabilitation and integration into the outpatient stroke clinic. Position is Full-time, M-F, business hours.

Entity

Medical University Hospital Authority (MUHA)

Worker Type

Employee

Worker Sub-Type​

Regular

Cost Center

CC000684 CHS - Stroke Program (Main)

Pay Rate Type

Salary

Pay Grade

Health-29

Scheduled Weekly Hours

40

Work Shift

Standard Day (United States of America)

Job Description

Position Overview: The Transitional Care Nurse (TCN) in the Outpatient Cerebrovascular Program reports directly to the Stroke Program Director and works collaboratively with the Comprehensive Cerebrovascular Medical Director and Stroke Clinic Nurse Practitioner(s). This role is essential in providing transitional care to stroke patients and their families, ensuring care continuity from acute hospitalization to rehabilitation and integration into the outpatient stroke clinic.

Schedule:

Full-Time (40 hours/week)

Monday-Friday

Business Hours

Key Responsibilities:

Transitional Care Delivery:

• Coordinate and deliver follow-up care via phone or webcam to stroke patients, assessing their medical conditions, functional status, and addressing new health issues.
• Review and manage medications, coordinate follow-up appointments, and connecting patients with necessary studies and community resources.

Education & Support:

• Serves as an educational resource to patients and families regarding stroke prevention, rehabilitation, and recovery.
• Provides patient/family education on stroke-related topics such as prevention medications, stroke rehabilitation, and lifestyle modifications.
• Assist patients and families with stroke recovery by facilitating support resources and providing clear guidance on recovery plans.

Collaboration & Coordination:

• Work closely with interdisciplinary teams, including vascular neurology, neurosurgery, neuroendovascular surgery, nurse case management, social services, smoking cessation counselors, dietary services, and community organizations.
• Ensure coordinated care by scheduling and tracking patient appointments, tests, and follow-up appointments with specialists.
• Address patient needs related to appointments, imaging, and testing, while also coordinating with outside institutions to retrieve medical records when needed.
• The TCN RN enjoys autonomy in managing and facilitating the care of stroke patients, while still being supported by a collaborative and interdisciplinary healthcare team.

Care Continuity:

• Ensure patients have access to essential services, from acute hospitalization through community integration (support groups, financial assistance, disability resources, etc.).
• Address social determinants of health, assisting patients with referrals to community services and overcoming barriers to healthcare access.

Triage & Communication:

• Manage patient care inbox messages, return patient calls, and triage concerns as needed.
• Conduct follow-up phone calls, including 2-day discharge calls, 7-day complex calls, and 90-day functional assessments (mRS scoring).

Program & Event Participation:

• Participate in stroke community events and represent the MUSC Comprehensive Stroke Program.
• Engage in educational opportunities, including care team education and stroke certification surveys.

Documentation & Reporting:

• Maintain accurate documentation of patient care, education, and follow-up, ensuring compliance with program standards.
• Contribute to program data tracking and quality improvement initiatives within the stroke program as needed.

Requirements (Education, Work Experience, Licensure, Registry &/or Certifications)

Qualifications for Transitional Care Nurse – Outpatient Stroke Clinic

• Education:
  • Bachelor of Science in Nursing (BSN) degree from an accredited college or university.
  • Alternatively, a Master of Science in Nursing (MSN) or Doctor of Nursing Practice (DNP) in lieu of a BSN.
• Work Experience:
  • A minimum of two to three years of experience in nursing, preferably in a clinical setting or neurology unit.
  • Experience in case management, social services, or care coordination is preferred.
• Skills & Competencies:
  • Excellent written and verbal communication skills.
  • Strong mentoring, coaching, and organizational skills.
  • Ability to work in a collaborative and team-oriented environment, coordinating care across multiple disciplines.
  • Strong ability to work autonomously in managing patient care and making independent decisions, while also collaborating effectively within a multidisciplinary team.
• Licensure & Certifications:
  • Current licensure as a Registered Nurse by the South Carolina Board of Nursing or a compact state.
  • Current Basic Life Support (BLS) certification from the American Heart Association (AHA) BLS for Healthcare Providers (or AHA-recognized equivalent), or American Red Cross CPR/AED for Professional Rescuers and Healthcare Providers.
  • Current or willingness to obtain Stroke Certified Registered Nurse (SCRN) certification and/or American Heart Association Acute Stroke Life Support (ASLS) certification.

This role requires a dedicated and highly skilled nurse with expertise in stroke care, patient education, and care coordination. The ideal candidate will possess a solid foundation in nursing practice and demonstrate a commitment to furthering their professional development in stroke care.

Physical Requirements

1) (C) Continuous – 6-8 hours per shift; 2) (F) Frequent – 2-6 hours per shift;  3) (I) Infrequent – 0-2 hours per shift  Ability to perform job functions while standing. (C). Ability to perform job functions while sitting. (C) Ability to perform job functions while walking. (Continuous) Ability to climb stairs. (I) Ability to work indoors. (C) Ability to work outside in temperature extremes. (I) Ability to work from elevated areas. (F) Ability to work in confined/cramped spaces. (F) Ability to perform job functions from kneeling positions. (I) Ability to bend at the waist. (C) Ability to twist at the waist. (F) Ability to squat and perform job functions. (F) Ability to perform “pinching” operations. (F) Ability to perform gross motor activities with fingers and hands. (C) Ability to perform firm grasping with fingers and hands. (C) Ability to perform fine manipulation with fingers and hands. (C) Ability to reach overhead. (F) Ability to perform repetitive motions with hands/wrists/elbows and shoulders. (C) Ability to fully use both legs. (C) Ability to use lower extremities for balance and coordination. (F) Ability to reach in all directions. (C) Ability to lift and carry 50 lbs. unassisted. (I) Ability to lift/lower object 50 lbs. from/to floor from/to 36 inches unassisted. (I) Ability to lift from 36” to overhead 25 lbs.  (I) Ability to exert up to 50 lbs. of force.  (F) Examples include: To transfer a 100 lb. patient that can not assist in the transfer requires 50 lbs. of force. For every 100 additional pounds, assistance will be required from another healthcare worker. 20 lbs. of force is needed to push a 400 lb. patient in a wheelchair on carpet. 25 lbs. of force is required to push a stretcher with a patient with one hand. Ability to maintain vision 20/40 corrected. (C) Ability to see and recognize objects close at hand or at a distance. (C) Ability to match or discriminate between colors. (C) Ability to determine distance/relationship between objects; depth perception. (C) Good peripheral vision capabilities. (C) Ability to maintain hearing acuity, with correction. (C) Ability to perform gross motor functions with frequent fine motor movements. (C) Ability to deal effectively with stressful situations. (C) Ability to work rotating shifts. (F) Ability to work overtime as required. (F) Ability to work in a latex safe environment. (C) *Ability to maintain tactile sensory functions. (C) *(Selected Positions) *Ability to maintain good olfactory sensory function. (C) *(Selected Positions) *Ability to be qualified physically for respirator use, initially and as required. (C) (Selected Positions)*

Additional Job Description

Bachelor’s degree in nursing required and three years related nursing experience. Licensure as a registered nurse by the South Carolina Board of Nursing or a compact state. Some positions require certification as a generalist in a related specialty area by the American Nurses Association (ANA). Licensure as a registered nurse by the South Carolina Board of Nursing or a compact state. Some positions require certification as a generalist in a related specialty area by the American Nurses Association (ANA). Current American Heart Association (AHA) Basic Life Support (BLS) certification or American Red Cross BLS for Healthcare Providers certification is required

If you like working with energetic enthusiastic individuals, you will enjoy your career with us!

The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.

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