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Mass General Brigham

Boston, Massachusetts

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Penn Medicine

Bala Cynwyd, Pennsylvania

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UC Irvine Hospital Medicine & Palliative Medicine

Orange and Irvine, California

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KeystoneCare Homecare - Palliative - Hospice - Private Duty

Wyndmoor, Pennsylvania

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UCSF at Zuckerberg San Francisco General

San Francisco, California

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Lifesong Hospice and Palliative Care

Harrisburg, Pennsylvania

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University of Vermont- Family Medicine

Burlington, Vermont

Lehigh Valley Health Network

Allentown, Pennsylvania

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Hospice & Community Care/Choices Healthcare

Lancaster, Pennsylvania

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Hospice & Community Care/Choices Healthcare

Lancaster, Pennsylvania

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Gilchrist Inova

Falls Church, Virginia

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University of Utah

Salt Lake City , Utah

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University of Maryland School of Medicine

Baltimore, Maryland

NYU Langone Health

Long Island, New York

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Cleveland Clinic Cancer Institute

Akron, Ohio

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Billings Clinic (health system)

Billings, Montana

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Transition Nurse Navigator, Transitional Clinic
Job DescriptionThe Comprehensive CARE Center is a transitional clinic that bridges the gap between discharge and community. The Transitional Nurse Navigator (TNN) follow patients that have recently discharged with a high risk diagnosis (CHF, COPD, Sepsis). Under general direction, this role is accountable for the high-risk patient population. Ensures the continuity and coordination of patient care delivery by assessing patient needs; developing transitional care plans; identifies and leverages appropriate resources; and evaluates patient progress. Communicates patient care updates and other relevant information to all stakeholders in a timely and reliable manner. Under general direction, this role is accountable for


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