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Care Transitions Nurse – Part-time – Remote

Job ID:


Full/Part Time:
Part Time

Waukesha W231N1440 Corp Ct –
Waukesha, WI 53186

Benefits Eligible:

Hours / bi-weekly pay period:

Responsible for ensuring an efficient and coordinated hospital discharge and transition process for patients recently hospitalized or treated in the emergency room that are at high risk for increased use of healthcare resources.

Identifies the needs of patients and families and coordinates internal and external community resources within the first month of hospital discharge to reduce post-hospitalization illness/disease.

Works closely with case manager to identify high risk patients. Creates a care plan to ensure patient has appropriate resources necessary to lower readmission rates.

Maintains caseload of patients following discharge to ensure patients receive appropriate home visits, are being seen by primary physicians and taking their medications as needed.

Facilitates communications between and negotiates with patient/family, physicians, nurses, dietary, rehab, homecare, social services and other disciplines that need to collaborate to provide care for the patient.

Identifies, evaluates and acts to resolve any potential barriers to delivery of care and a timely and appropriate discharge. May coordinate and document discharge plans of care.

Works closely with the medical staff, hospital departments and ancillary services in expediting care delivery and appropriate documentation to avoid delays in timely service provision. Validates care that is provided.

Collaborates as a partner with jointly assigned social worker to ensure safe and appropriate discharge planning.

Collaborates with physicians daily regarding patient care course. Makes suggestions in expediting care and modification to a tentative on a timely basis.

May works as a member of the Outcome Facilitation Team (OFT) in a collaborative and proactive manner to promote best practice. Works with the patient care manager and clinical nurse specialist of the unit to proactively achieve the objectives outlines in the multidisciplinary Outcome Facilitation Team meetings.

Scheduled Hours


Week 1: Thursday & Friday

Week 2: Monday, Tuesday, & Friday

Licenses & Certifications

Registered Nurse license issued by the state in which the team member practices.


Bachelor’s Degree in Nursing.

Required Functional Experience

Typically requires 2 years of experience in nursing in an acute care or community setting with an emphasis in palliative care or senior services.

Knowledge, Skills & Abilities

Excellent written and verbal communication skills. Strong organizational, analytical and problem solving skills.Ability to educate clinical staff and the community. Ability to work well with physicians and other healthcare professionals.Ability to work in a team based multidisciplinary environment.

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    Advocate Aurora Health is committed to diversity and inclusion every single day and in everything we do. Diversity lives in the differences, great and small, that matter to us and make each of us unique – from our age and the color of our skin, to our abilities and the things we believe in. We know that empowering our differences inspires creativity that leads to innovative solutions – for our team members, consumers and communities. And because health care is built upon relationships, it’s important for the people we serve to be able to trust us to meet their unique needs. By cultivating an atmosphere of acceptance and compassion, we create a welcoming environment where our patients can heal, our team members can thrive and our business can grow. As a team member, working in a diverse setting allows you the chance to grow in ways that will broaden your perspective to deliver the best possible patient care.