Transitional Clinic Nurse Navigator, Transition

Job Overview

We are seeking a dedicated and empathetic Transition Nurse Navigator (TNN) to become an integral part of our Comprehensive CARE Center team. This pivotal role is designed to facilitate the transition from hospital to home for high-risk patients, ensuring they receive the essential support needed for a successful return to community-based care. If you are committed to patient advocacy, care coordination, and enhancing health outcomes, we invite you to explore this opportunity.

Key Responsibilities

• Identify high-risk patients utilizing risk stratification tools (e.g., CHF, COPD, Sepsis).
• Perform comprehensive psychosocial evaluations and craft individualized transitional care plans.
• Engage in complex care planning through various channels, including telehealth, phone calls, and face-to-face meetings.
• Coordinate care transitions by scheduling follow-up appointments, arranging home health services, and maintaining continuity of care.
• Act as a vital liaison among acute care, ambulatory care, skilled nursing facilities, and hospice providers.
• Educate patients on effective disease management strategies, medication adherence, and self-care practices to improve clinical outcomes.
• Collaborate with social workers, pharmacists, community organizations, and other healthcare professionals to meet patient needs.
• Establish rapport with patients and families in the hospital setting to secure seamless care transitions.
• Facilitate interdisciplinary team meetings and ensure clear communication with all stakeholders.
• Assist patients and families with advanced care planning, including discussions around Advance Directives and MOLST forms.
• Implement evidence-based interventions such as IV initiation, lab draws, wound care, and symptom management.
• Maintain thorough and accurate patient records, ensuring timely documentation in electronic medical systems.
• Lead initiatives focused on process improvement and provide education to the care team regarding best practices in transitional care.
  
  

Required Skills

• Strong critical thinking and problem-solving capabilities.
• Proficient in connecting patients with community resources effectively.
• Knowledgeable in discharge planning, Medicare/Medicaid regulations, and post-acute care coordination.
• Excellent communication and collaboration skills with patients, families, and healthcare teams.
• Ability to prioritize tasks in a dynamic healthcare environment.
• Proficiency in data analysis and electronic medical records (EMR) systems.
  
  

Qualifications

• Required:
• Associate Degree in Nursing (ADN).
• Minimum of three (3) years of nursing experience.
• At least one (1) year of case management experience.
• Active Maryland RN license.
• Basic Life Support (BLS) certification.
• Preferred:
• Experience with quality-based reimbursement models, utilization management, or outpatient medical practice.
• Bachelor of Science in Nursing (BSN).
  

Career Growth Opportunities

Join a reputable organization dedicated to professional development and continuing education, where you can expand your skills and advance your career in transitional care.

Company Culture And Values

Be part of a supportive work environment that prioritizes employee well-being, collaboration, and innovation in patient care.

Networking And Professional Opportunities

Engage with a network of healthcare professionals, enhancing your skills and sharing knowledge to improve patient care outcomes.

Compensation And Benefits

• Competitive pay range: \(40.61 - \)60.96 per hour.
• Comprehensive benefits package, including health, dental, and vision coverage.
• Professional development and continuing education opportunities.
• Supportive work environment with a focus on employee well-being.
  
  

If you are ready to take on a meaningful role in transitional care and make a positive impact in the lives of patients and their families, we encourage you to apply today!

Employment Type: Full-Time