Remote Transitional Clinic Transition Nurse Navigator

Job Overview

We are looking for a dedicated and compassionate Transition Nurse Navigator to join our Comprehensive CARE Center, a transitional clinic focused on enhancing patient care continuity. This remote role is ideal for a skilled Registered Nurse (RN) who is committed to assisting high-risk patients in their healthcare transitions and improving their overall well-being.

Key Responsibilities

• Identify high-risk patients utilizing risk stratification tools.
• Conduct thorough assessments and consultations to formulate treatment and discharge recommendations, including remote patient monitoring.
• Deliver comprehensive care planning through a mix of telehealth, in-person meetings, and phone consultations.
• Oversee all facets of patients’ transitions of care, ensuring follow-up appointments, home health services, and transportation are well-coordinated.
• Facilitate effective communication among various care settings, including acute and ambulatory care, skilled nursing, palliative, and hospice care.
• Empower patients with education regarding disease management, medication adherence, and self-care strategies.
• Assess patient needs for appropriate referrals to relevant programs and services.
• Collaborate closely with inpatient teams, primary care physicians, and other professionals to ensure transition plans are actionable and effective.
• Foster rapport with patients during hospital visits to facilitate a smooth transition into outpatient care.
• Maintain strong relationships with patients, families, community organizations, and insurers.
• Work collaboratively on care plans that prioritize patient needs and objectives.
• Assist patients and caregivers in establishing advanced care plans, including Advanced Directives and MOLST.
• Implement evidence-based interventions and document all care provided accurately.
• Lead initiatives for program improvement and educate team members as necessary.
• Perform additional duties as assigned.
  
  

Required Skills

• An Associate Degree in Nursing is required.
• A minimum of three (3) years of nursing experience is mandated.
• At least one (1) year of prior case management experience is necessary.
• A current Maryland RN license and BLS certification are required.
• Excellent critical thinking and communication skills, both written and verbal.
• Familiarity with discharge planning concepts and guidelines.
• Ability to engage collaboratively with internal and external stakeholders.
• Flexibility to adapt to changing circumstances and environments.
• Strong decision-making and time management skills.
• Proficiency in computer applications, including word processing and data management.
  
  

Career Growth Opportunities

Joining our team offers meaningful opportunities for professional development. You will have the chance to enhance your skills, engage in program improvements, and contribute to the education of your colleagues, thereby fostering your career advancement.

Company Culture and Values

Our organization is committed to providing a collaborative and supportive environment where team members work together to empower patients and deliver outstanding care. We highly value communication, critical thinking, and adaptability, ensuring that everyone thrives in our dynamic healthcare setting.

Compensation And Benefits

• Competitive Compensation: \(40.61 - \)60.96 per hour.
• Comprehensive Benefits: Refer to the 2024-2025 UMMS Benefits Guide for detailed information.
  
  

If you are a compassionate RN eager to make a significant impact in patients’ lives, we invite you to apply and become part of our dedicated team!

Employment Type: Full-Time