Transitions of Care Registered Nurse

Hopscotch Primary Care

Hopscotch Primary Care

Asheville, NC, USA
Posted on Saturday, June 1, 2024

About Hopscotch Primary Care

At Hopscotch Primary Care, we believe great healthcare should be accessible to all people across all communities. Today, almost 20% of Americans live in a rural community, yet only 11% of physicians practice in those same communities. We are on a mission to transform healthcare in rural America. We provide high-quality primary care tailored to meet the needs of our patients through our robust care model and comprehensive care team, delivering care in our clinics, and across settings, and wrapping resources around the patients who need them most.

Our patients and the care teams who serve them sit at the center of everything we do at Hopscotch. Hopscotch Primary Care takes a team approach to serve patient needs and provide the best care possible. Our goal is to provide the care each of us would want for ourselves or for our family members, in the right setting, and at the right time.

Today, we are serving thousands of patients in our value-based care model and the number is growing every day. If you want to bring your experience, skill and passion to make a lasting impact in healthcare, we’d like to meet you.


As a Transitions of Care RN, you will lead an important function of the organization and care delivery model. This role will be responsible for ensuring a smooth transition from a hospital or post-acute setting to home. You will work with a diverse team including, but not limited to physicians, APPs, clinic care managers, community health workers, social workers, and others, to build long-lasting and trusting relationships with our patients and the broader healthcare ecosystems. This role is based in the Asheville area and will require travel around Western North Carolina.


Specific responsibilities for this role will include, but are not limited to:

  • Manage the inbound notifications feed related to transitions of care events
  • Support the technology and population health team to ensure accurate and timely notifications of admissions, discharges, and transfer events
  • Travel to local hospitals to round on any admitted Hopscotch Primary Care patients
  • Conduct outreach to patients following discharge to ensure discharge instructions are reviewed and post-discharge visit is scheduled
  • Request discharge instructions from hospital or post-acute facility and ensure they are prepped for the post-discharge visit
  • Conduct post-discharge medication reconciliation via telephone, in-person, or in-clinic
  • Using shared decision making with patients, create and monitor care plans during the transitions of care period to prevent readmissions
  • Ensures a smooth handoff from the transitions of care team to the clinic team
  • Partner with the Clinic Care Manager RNs on preventative care to support ED diversion and decrease hospitalizations
  • Other clinical duties as assigned


You would be a great fit for this position if you have a minimum of 5 years of experience as RN embedded into an interdisciplinary team and the following:

  • Active registered nurse (RN) license in North Carolina
  • BLS certification
  • Experience working in transitions of care or care management
  • Demonstrated ability to work closely with an interdisciplinary team with multiple providers
  • Clinical expertise in creating care plans during transitions of care
  • Knowledge of clinical guidelines and workflows for ED diversion, as well as decreasing admissions and readmissions
  • A problem-solving orientation and a flexible and positive attitude
  • Experience utilizing electronic medical record systems
  • Knowledge of community resources and resource navigation
  • Experience with motivational interviewing, behavior change, health promotion, and coaching
  • Strong verbal and written communication skills and customer service orientation
  • Accomplished problem-solving skills and a highly flexible and accountable work ethic
  • Willingness for daily travel within Western North Carolina
  • US work authorization

From a cultural perspective, you are:

  • Agile, yet thoughtful and can work effectively in a fast-paced, ever-changing environment
  • Constantly seeking ways to simplify and improve how things are done, bringing a positive attitude to challenges
  • Accountable, holding yourself and others to a high standard and seek to support and develop others
  • Willing to roll up your sleeves to support the work required and collaborate effectively with people of all backgrounds
  • Concise and articulate, drive towards clarity and deliver on your commitments
  • Collaborative, assuming positive intentions
  • Customer-focused, with a passion for serving patients and providers who make healthcare possible

At Hopscotch Primary Care, we embrace diversity, invest in a culture of inclusion and positivity and encourage all to apply to join our team. You will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.