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Registered Nurse (RN) - Transition of Care Nurse Case Manager
Recruitment/Relocation Incentives are not approved. The Transition of Care Nurse Case Manager works with the Transitions Specialty Team to develop and implement comprehensive patient care for the adult/geriatric patient population assessing, planning, implementing and evaluating activities and programs. Duties included, but are not limited to: During the transitional care period, ensures care coordination with the primary teams by discussing the veteran's post-hospital care plan with the primary inpatient team or inpatient RN, prior to discharge and by notifying the appropriate provider if problems/concerns arise during the transitional period. Uses validated protocols to provide coordinated complex case management to community-dwelling veterans at high-risk of poor post-hospital outcomes
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