Part Time Care Transitions Nurse - This is a part-time remote role that requires high-speed internet and requires some evening and weekend coverage. Care Transitions role for both 30 and 90-day programs Medicare/ACO patient population/Medicare FFS program post-hospital discharge.   

Position Requirements: Bachelor`s Degree in Nursing. Typically requires 2 years of experience in nursing in an acute care or community setting with an emphasis in palliative care or senior services. Excellent written and verbal communication skills. Strong organizational analytical and problem-solving skills. Ability to educate clinical staff and the community. Ability to work well with physicians and other healthcare professionals. Ability to work in a team-based multidisciplinary environment. Registered Nurse license issued by the state in which the team member practices. May need to operate a motorized vehicle to facilitate home visits as appropriate. Must be able to sit stand and walk without restriction. Must have the ability to move about in confined spaces including bending twisting kneeling squatting and occasionally reaching one or both arms overhead. Must be able to concentrate on detailed information, tasks and functions for prolonged periods of time. Must be able to speak clearly and hear in order to communicate in-person or via telephone.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties. Purpose: Responsible for ensuring an efficient and coordinated hospital discharge and transition process for patients recently hospitalized or treated in the emergency room that are at high risk for increased use of healthcare resources. Accountabilities: Identifies the needs of patients and families and coordinates internal and external community resources within the first month of hospital discharge.