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