Job Description
Are you a compassionate and experienced Registered Nurse (RN) passionate about helping patients navigate their healthcare transitions? Do you thrive in a collaborative environment where you can make a real difference in people's lives? If so, we have an exciting opportunity for you! We're seeking a dedicated Transition Nurse Navigator to join our team and provide vital support to high-risk patients in the Bel Air, MD area.
About the Role
Our Comprehensive CARE Center is a transitional clinic that bridges the gap between hospital discharge and community care. As a Transition Nurse Navigator, you'll be a vital link in ensuring seamless continuity of care for patients with high-risk diagnoses like CHF, COPD, and Sepsis. You'll assess patient needs, develop personalized transitional care plans, connect patients with appropriate resources, and monitor their progress. Your expertise and support will empower patients to manage their health and thrive in their community.
What You'll Do
Identify high-risk patients using risk stratification tools.
Conduct comprehensive assessments, consultations, and develop treatment and discharge recommendations, including remote patient monitoring.
Provide complex care planning via phone, in-person meetings, and telehealth.
Coordinate all aspects of patients' transitions of care, including follow-up appointments, home health, community services, and transportation.
Facilitate communication between all care settings (acute care, ambulatory, short stay, skilled nursing, palliative care, and hospice).
Empower patients through education on disease management, medication, access to care, and self-care strategies.
Identify patient needs and make appropriate referrals to programs and services (e.g., social workers, pharmacists, community agencies).
Consult regularly with the inpatient team, primary care physicians, supervisors, and other team members to ensure transition plans are relevant and achievable.
Meet with patients in the hospital to build rapport and facilitate a smooth transition to the outpatient setting.
Maintain strong relationships with patients, families, community agencies, and payers.
Collaborate and implement care plans, prioritizing patient needs and goals.
Proactively work with patients, caregivers, and care teams to identify advanced care plans, including Advanced Directives and MOLST.
Implement plans of care using evidence-based interventions and treatments.
Maintain accurate and complete records, documenting all care provided, patient information, communications, and care management decisions.
Lead program improvements and provide education to the team.
Perform other duties as assigned.
What You'll Bring
Associate Degree in Nursing (required).
Minimum three (3) years of previous nursing experience (required).
One (1) year of previous case management experience (required).
Current Maryland RN license (required).
BLS certification (required).
Effective critical thinking and communication skills (written and oral).
Knowledge of discharge planning concepts and guidelines.
Ability to collaborate effectively with internal and external customers.
Ability to adapt to changing and/or crisis environments.
Strong decision-making skills.
Excellent time management and prioritization skills.
Computer literacy (word processing, Excel, data management).
Bonus Points For
Experience with quality-based reimbursement models, utilization management, or outpatient medical practice.
Bachelor of Science in Nursing.
What We Offer
Meaningful Work: Empower patients to navigate their healthcare journey with confidence.
Collaborative Environment: Work alongside a dedicated and supportive team.
Competitive Compensation: $40.61 - $60.96 per hour.
Comprehensive Benefits: Review the 2024-2025 UMMS Benefits Guide for details.
Professional Growth: Opportunities to develop your skills and advance your career.
Join Us!
If you're a compassionate and experienced RN looking for a rewarding opportunity to make a real difference in patients' lives, we encourage you to apply! We're excited to hear from you.
Employment Type: Full-Time
Salary: $ 111,297.00 Per Year
Job Tags
Hourly pay, Full time, Remote job,