Registered Nurse (RN) | Care Transitions

Manages the care of patients referred to the Care Transitions program. Performs patient assessment and develops a patient-centered plan of care including follow-up phone calls and home visits. Addresses clinical concerns, provides education, makes referrals to appropriate resources and services, assists with access to care, improves care coordination and assures an effective discharge plan for patients at the end of the Care Transitions service. Develops patient care plans in accordance with established protocols. Maintains contact with referring facilities, agencies, and community resources.