Transitional Nurse Navigator

Job Description

Job Description

Company Description

University of Maryland Upper Chesapeake Health (UM UCH) offers the residents of northeastern Maryland an unparalleled combination of clinical expertise, leading-edge technology, and an exceptional patient experience.

A community-based, integrated, non-profit health system, our vision is to become the preferred, integrated health system creating the healthiest community in Maryland. We are dedicated to maintaining and improving the health of the people in our community through an integrated health delivery system that provides high quality care to all. Our commitment to service excellence is evident through a broad range of health care services, technologies and facilities. We work collaboratively with our community and other health organizations to serve as a resource for health promotion and education.

Today, UM UCH is the leading health care system and second largest private employer in Harford County. Our 3,500 team members and over 650 medical staff physicians serve residents of Harford County, eastern Baltimore County, and western Cecil County.

University of Maryland Upper Chesapeake Health owns and operates :

Upper Chesapeake Medical Center (UM UCMC), Bel Air, MD

The Upper Chesapeake Health Foundation, Bel Air, MD

The Patricia D. and M. Scot Kaufman Cancer Center, Bel Air, MD

The Senator Bob Hooper House, Forest Hill, MD

Job Description

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.

Job responsibilities :

• 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.

Qualifications

Education & Experience - Required

Education & Experience - Preferred

Additional Information

All your information will be kept confidential according to EEO guidelines.

Compensation

Review the 2025-2026 UMMS Benefits Guide

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