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Supervisor RN Transitional Care - Care Continuum Community Health
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Full-time
- Transitional Care Navigator serves as an educational resource for patients, care givers and staff members.
- Transitional Care Navigator performs overall coordination of care for identified patients via telephonically or on-site such as at hospitals, in-home, or various placements after discharge.
- The Transitional Care Navigator plans effectively to meet patient needs during their hospital stay regarding processing them through the system and managing the length of stay, promoting efficient utilization of resources, and plans for a safe discharge continually evaluating and updating patient status.
- Document interactions and interventions as directed with health technology, risk stratification and patient engagement tools.
- Provides health coaching activities across the continuum of care in order to facilitate and promote high quality, cost-effective outcomes, focused on the whole patient orientation and self- management decision support and aims to minimize any fragmentation of health care delivery.
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