Works with care teams and technology to identify high-risk, high-need patients, implement best practice processes for chronic care and disease management (CHF, AMI, COPD, PNA, CABG and TKR/THR), provide patient education, and refer patients to available health resources when appropriate. Working within a defined patient population, the RN Transitional Care Navigator assesses, develops, implements, coordinates, monitors, and evaluates care plans and disease-specific education to optimize patient health outcomes and resource utilization across the care continuum.