Transition Nurse Navigator

University of Maryland Medical System Bel Air, MD 21014, US

$40.62 - $60.96 / hour

Job Requirements

Full-time role - Monday - Friday 8:00 am - 4:30 pm EST

Job Summary

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.

Primary Responsibilities

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job responsibilities performed.

Identifies high risk patients using prospective risk stratification tools (e.g., high risk diagnosis, readmission risks, etc.)
Evaluates patient and family’s psycho-social and medical complexities to determine the transitional care plan.
Monitors EMR daily to ensure follow-through on consultations, appropriate medication management, and treatment plan.
Communicates and collaborates daily with the multidisciplinary team including inpatient hospitalist team, nursing, specialists and other members of care team to ensure that the medical care plan is being met.
Educates patients and families on chronic disease management, medication management, and access to care to improve clinical outcomes and promote patient self-care.
Coordinates follow-up care in collaboration with the inpatient teams and the Comprehensive care center (appointments, home health, remote monitoring, SNF).
Identifies patient needs and makes appropriate referrals to programs/services (i.e. case management, pharmacist, community agencies, etc.)
Collaborates and implements plans in accordance with established policies, prioritizing patient care goals and needs. Meets with patients, patient families, and caregivers as needed to discuss transitional care and treatment plans.
Facilitates interdisciplinary team meetings to coordinate medically complex cases to reduce the length of stay and avoid readmissions.
Works proactively with patients, caregivers, and patients care team to identify an advanced care plan.
Maintains accurate and complete records, initiates and oversees data entry into IT systems, documents all care rendered, pertinent patient information, all communications, and all care management decisions in appropriate database/electronic record.
Acts as lead on programs, identifying improvements and putting changes in place to better assist the high-risk population. Provides education to the team on information that will benefit patient outcomes.
Perform all other related duties as assigned.

Work Experience

Education & Experience - Required

Associate Degree in Nursing required.
Minimum three (3) years of previous nursing experience required.
One (1) year previous case management experience.
Current Maryland RN license required.

Education & Experience - Preferred

Experience with quality-based reimbursement models, utilization management is preferred.
Bachelor of Science in Nursing is preferred.

Compensation

Benefits

Pay Range: $40.62 - $60.96

Other Compensation (if Applicable)

Review the 2025-2026 UMMS Benefits Guide

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