Summary This Registered Nurse position is located in the Medical Service at the West Roxbury campus location of VHA Boston. This position is full-time at 40 hours per week. Responsibilities Collaborate with inpatient teams to identify Veterans with complex medical and social needs and serious illness for enrolment in Supportive Coordinated Transitional Care (CTraC) Program Provide post-discharge care coordination, education, anticipatory symptom management, and alignment with goals of care Coordinate care between inpatient and outpatient palliative care, geriatrics, prosthetics, rehabilitation medicine, and pharmacy teams Provide outpatient clinic support to include triage of consults, hospice referrals, responding to veteran and family calls and secure messages, symptom assessment and collaboration with providers. Facilitate hospice referrals to home and other facilities including in other states. Collaborate closely with hospice agencies and social work. Provide nursing and clinician...