RN-Transitional Care

Promotes patient-centered care among the healthcare team by providing coordination, collaboration and clinical expertise to meet patient needs during the transitional period and achieve optimal outcomes. Promotes prudent utilization of all resources. Serves as the patient's advocate by coordinating resources and services necessary to meet the patient's continuing care needs. Ensure flow of medical information between providers and points of care and close gaps where possible. Responsible for coordinating care and provide follow up during the transitional period after discharge. Performs other duties as assigned.