Chronic Care & Transitional Care Management Nurse

The Chronic Care & Transitional Care Management Nurse coordinates care for high-risk, chronically ill patients, including those receiving palliative care, to support value-based care initiatives. This role involves leading care coordination, transitional care outreach, medication reconciliation, and quality metric monitoring while partnering with providers and clinical staff. The position requires identifying eligible patients, conducting post-discharge outreach, and ensuring safe transitions of care through effective communication and documentation.