Job Description

This Transition of Care Nurse is a full time position supporting patient transition of care - case management located in the Administrative Services Building at 6180 N. Corona Road.

Contact patients discharged from hospital and/or post acute care facility and assess complexity of health issues and schedule patient for appropriate Transition of Care visit.

  1. Provides competent, safe and timely patient Transition of Care planning care utilizing the nursing process.
  2. Accurately and legibly documents all assessments, interventions and transition of care according to policies and procedures.
  3. Retrieve and review hospital and/or post acute care records and gain an understanding of patient health issues.
  4. Utilizing policy and procedures assess if patient is eligible for Transition of Care (TCM) visit.
  5. Contact patients identified as TCM candidates within 48 hours of discharge and through inquiry determine if patient is required to be seen within 7 or 14 days by PCP.
  6. Schedule patient TCM visit with appropriate Northwest Allied Physician clinician based on Policy and Procedure.
  7. Clearly and consistently document in the data system and save all TCM related decisions.
  8. Enhances professional growth and development through participation in educational programs, current literature, in-services, and meetings.
  9. Accurate documentation of all medication changes while in hospital or post acute care facility.
  10. Performs other job duties relevant to the position as assigned.


Education:  Post High School Vocational/Specialized Training in Practical Nursing required.                       

Experience:  Minimum of one (1) year of clinical experience in area of expertise preferred.   

Northwest Healthcare is a multi-faceted network dedicated to providing safe, quality care at each of our locations.  With two (soon to be three) hospitals, two freestanding emergency centers, five urgent care locations and a large physician practice including primary care and a variety of specialists, Northwest Healthcare offers you a wide range of settings in which to work.  Common among them all is not only the commitment to providing safe patient care, but to employee satisfaction and growth.  It is a culture of teamwork, respect and appreciation for all employees—whether caring for patients directly or working in a support role.  NWHC is accredited by The Joint Commission and is an equal opportunity employer:  race, gender, disability and Veteran status, and VEVRAA Federal Contractor – priority referral Protected Veterans requested.



Case Management


Application Instructions

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