Ambulatory Nurse Navigator

Coordinate patient care and transitional services following hospital admissions, discharges, and ED visits by assessing, managing, and monitoring individualized primary and social needs using RPM technologies. Monitor vital signs, symptoms, and medication adherence; provide timely interventions, comprehensive preventive screenings, and health coaching to engage patients in their care plans. Conduct outreach to close care gaps, initiate annual wellness visits, and facilitate advanced care planning discussions. Identify workflow opportunities to improve patient care while integrating into the clinic as a core team member.