Registered Nurse (Transition of Care)

Full Time




Under the supervision of the Registered Nurse Clinical Program Manager (Transition of Care), the Registered Nurse (RN) (Transition of Care) provides support for specific Unity Health Care programs which seek to improve health outcomes for complex, vulnerable patients and their families through intensive care coordination activities.  The RN (TOC) will be an integral member of a multidisciplinary outreach team in a variety of Washington, DC settings, including the hospital, primary care offices, patient homes, medical day centers, homeless shelters, and various other community settings.



The primary responsibilities of this position include:

·         Assists with the development, maintenance, and adjustment of individualized care plans for high-risk patients that address both medical and social barriers to accessing care, documenting accordingly in the EMR (medical record).

·         Works alongside the Registered Nurse Clinical Program Manager and Community Health Worker to screen and enroll recently hospitalized patients, complete intake assessment, initiate care plan including medical needs/barrier identification of patients enrolled in the program; coordinates and/or delegates tasks with team members.

·         Coordinates interventions on behalf of families to reduce barriers due to social determinants of health.

·         Addresses clinical emergencies according to protocol or general standard of care guidelines.

·         Leads data-driven, rapid cycle improvement processes with regard to clinical interventions.

·         Promotes activities related to the delivery of clinical services including, but not limited to, utilization review, quality assurance and clinical protocol development.

·         Plans and executes interdisciplinary case conferences/team meetings and clinical rounds.

·         Forges and nurtures partnerships with hospitals, medical offices, and local service organizations to broaden support services for patients.

·         Acts as a liaison between hospitals, primary care providers, specialists, community resources and Managed Care Organizations on behalf of enrolled patients to ensure patient-centered care coordination.

·         Oversees clinical activities of staff and provide guidance and support regarding direct patient care.

·         Enters and maintains electronic records, reviews notes compiled by others as needed, and compiles/completes reports and other program documentation in a timely manner (e.g., tracks via progress notes, incident reports, client track, letters, etc.); performs other administrative responsibilities as needed.

·         Assists Program Director(s) with additional special projects and administrative assistance.

·         Plays a consistent and active role in identifying project inefficiencies and finding collaborative solutions to the problems.

·         Represents the program at various local, state, and national meetings.

·         Attends relevant training as necessary to maintain professional certification and/or knowledge.

·         Adheres to Unity's HIPAA guidelines and ensures the appropriate handling of sensitive information.

·         Completes special projects specific to the function of the program and/or organization.

·         Performs other duties as assigned within the scope of position expectations.



  • Must be a Registered Nurse licensed to practice in Washington, DC (BSN required).

·         Maintains current CPR certification.

·         Must be a graduate of an accredited school of nursing (MSN Preferred).

·         Experience working as a part of an interprofessional team, including but not limited to social services; Familiarity with the role of Community Health Workers.

·         Familiarity with community health, discharge planning, chronic disease management

  • Minimum of 2 years of experience providing clinical services; experience in a hospital and/or community/outpatient setting preferred.
  • 1-2 years of demonstrated leadership abilities in a clinical setting.


  • Demonstrated ability to communicate and drive outcomes across professional disciplines, organizations and clinical settings especially on behalf of medically and socially vulnerable populations.
  • Ability to effectively provide clinical care to socially and medically complex patients in a variety of non-traditional settings; experience in serving in poor, urban environments; familiarity with Washington, DC is preferred.
  • Exceptional interpersonal and organizational skills, with attention to detail required; strong oral/written communication skills are a must.
  • Exceptional computer skills (i.e., Microsoft Office Suite, EMR).
  • Ability to work collaboratively in a team and manage multiple priorities, utilize effective time management skills, and exercise sound administrative and clinical judgment.
  • Demonstrated ability to work well with people of various ages, backgrounds, ethnicities, and life experiences.
  • Proven ability to work collaboratively and productively with clinicians, administrators, patients, and other individuals from various backgrounds and skill sets.
  • Requires the ability to travel to multiple office locations.