Transitional Care Nurse - Full Time Days
: Job Details :

The Transitional Care nurse (TCN) will ensure the coordination and continuity of healthcare as patients transition between different locations or levels of care. The TCN will assist with complex patients, focus on high hospital utilizers, chronically ill and educate patients and family caregivers to determine the root cause to poor health outcomes that may lead to readmission to the hospital. The TCN will work with the Manager of Case Management, Care Managers and hospitalists to determine a safe discharge plan and ensure patients continuity of care upon discharge. ESSENTIAL DUTIES AND RESPONSIBILITIES - Responsible for post discharge contact on a case-by-case concern with Medicare, other payers, and other identified complex patients, observation and inpatient, to determine that a safe discharge plan has been fully implemented. Works with the Manager of Post-Acute Services Care Networks, Care Management Manager, Social Work and other members of the CM team to identify patients requiri...Nurse, Management, Health, Manager, Patient Services, Healthcare