Registered Nurse Triage and Transition Team
Core
Provides time-limited, comprehensive care management services to patients and families, ensuring continuity of care across healthcare settings and preventing health complications.
Role type
Registered Nurse Triage and Transition Care Manager
Builds
Individualized care plans, care recommendations, and referrals for patients moving across care settings
Domain
Healthcare / Post-acute care / Chronic disease management
Required skills
Clinical nursing assessment, Care plan management, Transitions of care coordination, Acute symptom triage, Patient education, Multidisciplinary collaboration, Data analysis, Root cause analysis
Preferred skills
Care Management Certification, Ambulatory transitional care experience, Telephonic triage experience
Technologies
Microsoft Office, Electronic Health Records (implied via medical record review)
Responsibilities
Identify patients for proactive interventions using screening criteria and medical risk scores; Conduct remote nursing assessments to determine appropriate care recommendations; Coordinate with internal and external services for social determinants of health needs; Analyze data on readmissions and utilization trends to improve care processes; Educate patients and healthcare team members on transitions and self-management.
Seniority
Mid-level, hands-on IC