Job Description
We are looking for a compassionate and dedicated Transition Nurse Navigator (TNN) to join our Comprehensive CARE Center team. This role is designed to bridge the gap between hospital discharge and community-based care, ensuring that high-risk patients receive the support they need for a smooth transition back home. If you're passionate about patient advocacy, care coordination, and improving health outcomes, this could be a great opportunity for you!
What You'll Do:
Identify high-risk patients using risk stratification tools (e.g., CHF, COPD, Sepsis).
Conduct comprehensive psychosocial assessments and develop personalized transitional care plans.
Provide complex care planning through phone calls, in-person meetings, and telehealth visits.
Coordinate care transitions, including scheduling follow-up appointments, arranging home health services, and ensuring continuity of care.
Serve as a key liaison between acute care, ambulatory care, skilled nursing facilities, and hospice providers.
Educate patients on disease management, medication adherence, and self-care to enhance clinical outcomes.
Collaborate with social workers, pharmacists, community agencies, and other healthcare professionals to address patient needs.
Meet with patients and families in the hospital setting to establish rapport and ensure seamless care transitions.
Facilitate interdisciplinary team meetings and maintain effective communication with all stakeholders.
Assist patients and families with advanced care planning, including discussions around Advance Directives and MOLST forms.
Perform evidence-based interventions, such as IV initiation, lab draws, wound care, and symptom management.
Maintain accurate patient records, ensuring timely and complete documentation in electronic medical systems.
Lead initiatives for process improvement and provide education to the care team on best practices for transitional care.
What You Bring:
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 in quality-based reimbursement models, utilization management, or outpatient medical practice.
Bachelor of Science in Nursing (BSN).
Skills & Abilities:
Strong critical thinking and problem-solving skills.
Ability to connect patients with community resources effectively.
Knowledge of discharge planning, Medicare/Medicaid guidelines, and post-acute care coordination.
Excellent communication and collaboration skills with patients, families, and healthcare teams.
Ability to manage priorities in a fast-paced healthcare environment.
Proficiency in data analysis and electronic medical records (EMR) systems.
Compensation & 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.
Join a team that is making a difference in the lives of patients and their families. If you're ready to take on a meaningful role in transitional care, apply today!
Employment Type: Full-Time
Salary: $ 40.00 60.00 Per Hour
Job Tags
Hourly pay, Full time,