Under general supervision, provides patient education, support, and interventions to optimize care transitions. Assists in Plan of Care compliance. Includes coordination of Home Health, Remote Patient Monitoring (RPM), Durable Medical Equipment, Pharmacy as needed and communication with physicians. Uses a process of nursing intake, assessment, planning, and care in accordance with physician orders, the established plan of care, the patient's diagnosis, policies and procedures, and the Nurse Practice Act. Essential Functions: • Serves as point of contact, clinical leader and resource to staff and administration. * Provides patients and family with needed information for the transition from active treatment to managing their condition independently. * Functions as a member of an inter-disciplinary team, encouraging and maintaining open communications. * Provides clinical supervision to the Care Transitions Tele Med-Assistant for patients and provides input regarding his/her performance to the appropriate manager. * Assists in the orientation of new staff or continuing education of existing staff as requested. • Helps to identify patients who are appropriate for RPM. • Establishes vital sign parameters, obtains physician orders, develops a plan of care, and documents findings. • Develops and maintains rapport with patients and caregivers via phone and/or video communication. • Responsible to continually assist patient/family through the healthcare system which includes during procedures/admissions at TGH, follow up, and with community resources. * Assesses and evaluates patient data and needs; providing appropriate support. Patient/family health education, direction, and intervention. • Notifies physician and other care agencies of changes in patient condition or status, sends reports, obtains new orders, and modifies the care plan as needed. • Identifies the need for and recommends appropriate disciplines and community resources for optimum patient care. • Maintains clinical skills within nursing practice norms and participates in group projects, training, and education as needed. • Informs department manager of perceived problem areas related to program, patient care, or community relations. • Demonstrates a professional attitude, sound judgment and continuity in interactions with physicians, other health care providers, and community agencies. * Acquires and utilizes knowledge of community resources. * Demonstrated clinical, interpersonal and communication skills. Education Qualifications • Bachelor’s Degree Nursing Licenses and Certifications • Registered Nurse Experience Qualifications • Minimum of three (3) years of nursing experience, including experience in care coordination, ambulatory, post‑acute, or transitional care settings. Skills and Abilities • Knowledge of care transition principles, chronic condition management, and ambulatory workflows. • Ability to assess patient needs, coordinate multidisciplinary care, and support plan‑of‑care compliance. • Strong communication and interpersonal skills to engage patients, caregivers, and care teams. • Ability to manage multiple patients and priorities in a fast‑paced clinical environment. • Proficiency with electronic medical record systems and clinical documentation standards.