Registered Nurse-Patient Centered Home Care

MUSC is recruiting a Transition Care Nurse (RN) for the population health team at MUSC Community Physicians. The hourly role carries 40 scheduled weekly hours and is listed as remote. It helps patients move safely from hospital back to everyday care by making sure the transitional care steps are completed, which supports value-based care goals.

The nurse phones patients soon after hospital discharge, reviews discharge paperwork, and distributes cases to team members by acuity. Every call is logged, and any issue needing provider attention is raised. The nurse reinforces discharge instructions, explains why primary-care follow-up matters, helps schedule timely visits, performs medication reconciliation and flags mismatches to the primary care team, and refers patients to community services as the care plan requires. The nurse also tracks data that shows the program's impact, supports higher-acuity cases, and works to prevent avoidable emergency use after discharge.

The posting lists an associate degree in nursing as required, along with two or more years of clinical RN experience. Experience in community outreach education, care coordination, primary care or health teaching is preferred. Customer-service skill, independent work habits and fast reprioritization are expected. South Carolina RN licensure or a compact-state license is required, with current Basic Life Support certification, though remote population health roles are exempt from BLS. A different section mentions a bachelor's in nursing plus three years of experience, so applicants should check which standard applies.

The physical requirements section describes long periods of standing or sitting, fine motor skill, vision and hearing needs, and the stamina for clinical work. No salary amount is given.