The Transition Care Nurse is responsible for contacting patients post discharge and helping coordinate care for patients with chronic conditions like AMI/CABG, Heart Failure, COPD. The nurse will collaborate with providers and hospital team members to ensure the patient has everything needed to recover safely in the home setting, to identify any complications/issues that the patient may be experiencing, to remove barriers, improve outcomes, and enhance satisfaction. The nurse also ensures that appropriate follow-up appointments are scheduled and a plan is in place for the patient to attend the appointment. The Transition Care Nurse will follow guidelines set for timeframes for completion of calls for those patients identified as high risk for readmission. Employee must be able to successfully complete job specific orientation and meet or exceed standards as identified in the criteria-based performance appraisal.
Required Qualifications/Experience:
Preferred Qualifications/Experience:
Deaconess Health System is the premiere provider of health care services to a population of more than 1.5 million in southwestern Indiana, western Kentucky and southeastern Illinois. Serving a population of more than 1.5 million residents, the system consists of 20 wholly owned, joint ventured, sponsored or affiliated hospital locations situated throughout the Tri-State.
Deaconess Health System is the largest employer in the tri-state region, and operates under the direction of a local board, with a local focus. Deaconess is widely recognized for its commitment to excellence. Named the #2 Hospital in Indiana by US News & World Report for the past six years, Deaconess was also named to the Forbes list of America’s Best Employers in 2022 and 2023, 2024 and 2025.
As our organization continues to grow and expand, we welcome skilled, dedicated and compassionate individuals to join us in delivering The Deaconess Difference: putting people at the center of everything we do, making a positive difference in the lives of our patients, families, employees and community.
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Our commitment to progressive, patient-centered care guides our work every day as our priorities are set and decisions are made with a local focus and direction.
