Job DescriptionThe Transitional Nurse Navigator (TNN) is responsible for seeking and implementing interventions, methodologies, and best practices for the high-risk population. Using an evidence-based tool, the TNN identifies and assesses the patient for priority needs, key areas for needed support and services that contribute to readmissions; develop care plans and when appropriate refers for services to assist in navigating barriers to care. Will effectively collaborate and communicate with internal and external customers to maximize the patient's potential for a healthy lifestyle evidenced in reduced Emergency Department visits and readmissions to the hospital. Effective use of data is a responsibility of this rol