PHSO Transitions of Care RN - Hybrid [Urgent Search]

Company: The University of Vermont Health Network
Location: South Burlington
Posted on: July 16, 2025

Job Description:

Job Description The Population Health Service Organization (PHSO) Department is hiring for a Transitions of Care RN to join their team! This is a hybrid position, allowing for primarily remote work, supporting UVM Health Network Primary Clinics' transition of care calls. WHO WE ARE: The UVMHN (University of Vermont Health Network) PHSO (Population Health Services Organization) is a physician and payer partnered operation that provides the right constellation of services (e.g. care management and care coordination, data and analytics, provider reporting, Quality, Risk Adjustment, and Value-based Contract Performance, etc.), that enables the health network to successfully perform in High Value Care and Value-Based Contracts. JOB DESCRIPTION: The PHSO Transitions of Care (TOC) RN will provide advanced professional nursing care to patients in varying states of health and illness through assessment, planning, implementation, and evaluation of the patient's healthcare needs. The TOC RN will provide direct care to patients and families, after a recent Inpatient, Emergency Room, or Urgent Care discharge using critical thinking skills to assist in the assessment of the patient’s needs to determine the right place, right time, and right next step for care. This role will collaborate with the patient’s healthcare team to provide quality care while using the Organizational Standards of Patient Care and Nursing Practice to help guide the delivery of nursing services. The TOC RN will demonstrate dedication to professional growth, development, and to the continuous improvement of patient care. Primary duties for this role will involve telehealth-based triage services. EDUCATION: State of Vermont Registered Nurse (RN) license required. The University of Vermont Medical Center is moving toward an all Bachelor of Science in Nursing (BSN) workforce. All external candidates hired into, or current employees promoted to, a RN position will be required to obtain their BSN as outlined in the terms of their offer letter. Current internal RNs are strongly encouraged to pursue a BSN to support this initiative. EXPERIENCE: 2-3 years of experience in relevant clinical area and/or independent in all areas of the Staff Nurse II accountabilities. WHY UVM HEALTH NETWORK (UVMHN)? As a team, The University of Vermont Health Network improves the lives of our patients by delivering outstanding care cost-effectively, as close to patient's homes as possible. Working together to better serve our communities makes us stronger, focused on collaboration instead of competition. BENEFITS: At UVMHN, we support our employees as passionately as we care for our patients. We offer a comprehensive, total compensation package that includes salary, health and wellness benefits, paid time off, and more. - https://www.uvmhealth.org/medcenter/health-careers/benefits LEARN MORE: - What is it like working here? https://www.uvmhealthnetworkcareers.org/diversity-equity-inclusion.html - Find more information about the University of Vermont Health Network here: https://www.uvmhealth.org/about-uvm-health-network

Keywords: The University of Vermont Health Network, Worcester , PHSO Transitions of Care RN - Hybrid [Urgent Search], Healthcare , South Burlington, Massachusetts