Care Transitions Nurse (RN)

Care Transitions Nurse (RN)

Employment Type: Full-time - Days

Schedule: Monday - Friday, 8-hour days

Compensation: Salaried/Exempt starting: $76,000

Primary Location: Main Hospital - Grand Rapids, MI

Department Name: Inpatient Acute Rehab

Other Benefits: Annual Merit Increases, Health Insurance (Medical, Dental, Vision), PTO, Holiday Pay, PSLF Eligible, Tuition Reimbursement

Summary

The Care Transitions Nurse is a registered nurse responsible for supporting high-risk patients during the transition from the inpatient acute rehabilitation hospital to home or other care settings. This role focuses on reducing avoidable 30-day readmissions by conducting timely post-discharge outreach, identifying and addressing clinical and social barriers, reinforcing discharge instructions, and providing care coordination that is patient-centered and focused on safety.

The Care Transitions Nurse serves as a liaison between the patient, healthcare team, and community resources. The nurse works collaboratively with the interprofessional team to decrease hospital readmission rates and improve patient satisfaction following discharge.

Essential Job Responsibilities

• Provide patient care, treatment, and services within the scope of their license, certification or registration and as required by Federal and State laws and regulations.
• Promote a culture of safety for all patients served by adhering to all applicable department policies and procedures. Demonstrates understanding and actively contributes to patient safety initiatives.
• Monitor assigned post-discharge patients across the continuum of care; identify and notify the appropriate care team of any readmissions, including known contributing factors. Document all relevant information to support readmission tracking and analysis.
• Conduct timely post-discharge follow-up calls and proactively identify, address, and resolve clinical, social, and system-related barriers to recovery.
• Collaborate with post-acute care providers, community agencies, and interdisciplinary teams to coordinate services and secure necessary resources for patients, families, and caregivers.
• Maintain accurate tracking logs and collect performance data as assigned; partner with acute and post-acute providers to identify and mitigate barriers to safe, effective, and timely transitions of care.
• Participate in 30-day readmission reduction initiatives, task forces, and quality committees as assigned.
• Collaborate with quality and operational teams to design, implement, and evaluate process improvements that enhance care transitions and reduce readmissions.
• Provide timely feedback to leadership regarding program performance, opportunities for improvement, and barriers impacting patient outcomes.
• Demonstrate clinical expertise, care coordination, and effective communication to support patients and families throughout the continuum of care.
• Perform other duties as assigned.

We'll embrace all people by:

• Treating everyone with dignity and respect.
• Opening more doors to opportunity for others to succeed.
• Growing talent and people.
• Ensuring a welcoming experience for all we serve, regardless of origin, race, religion, disability, sexual orientation or socioeconomic status.
• Taking action against discrimination.
• Honoring our differences and how we collaborate.
• Educating staff, patients and the communities we care for.
• Restoring hope and freedom, together.

Customer Service Responsibilities

Demonstrate excellent customer service and standards of behaviors as well as encourages, coaches, and monitors the same in team members. This individual should consistently promote teamwork and direct communication with co-workers and deal discretely and sensitively with confidential information.

Responsibilities in Quality Improvement

Contribute by identifying problems and seeking solutions. Promote patient/family satisfaction where possible; participates in departmental efforts to monitor and report customer service.

Essential Job Qualifications

• Licensure:

• Registered nurse in the state of Michigan.

• CRRN Requirement: All newly hired staff will be required to become a Certified Rehabilitation Registered Nurse (CRRN) by their 3rd anniversary with Mary Free Bed. Mary Free Bed will fund training and certification towards CRRN certification.

• Current Basic Life Support (BLS) certification

• Education: Associate's degree in nursing is required. Bachelor's degree preferred. Certification as a Registered Rehabilitation Nurse is preferred and will be encouraged for all MFB RNs.

• 5 years of experience as an RN, preferred experience in a rehabilitation or acute care setting.

• Strong critical thinking, decision-making, delegation, and leadership skills are required to work as an RN in the Nursing Department at MFB.

• Time management and organizational skills are very important, as well as effective written and verbal communication skills.

• Must be able to work effectively under time requirements and deadlines, problem-solve when facing unexpected issues, handle interruptions, and prioritize effectively.

• Sense of urgency, collaborative team style, and ability to quickly adapt to changes in priorities with strong decision-making skills.

• Excellent analysis and decision-making skills with ability to interpret clinical and analytical assessments

• Ability to multi-task for timely project completions.

• Effective written and verbal communication skills.

• Information-management skills and ability to interpret, communicate, and present data.

• Ability to work independently with critical thinking skills when assessing patient needs.

• Strong knowledge of acute care and post-acute services and their differences

• Excellent communication and presentation skills

• Excellent customer relations skills

• Impeccable time management skills

• Demonstrated results orientated

Preferred Job Qualifications

• Understanding of insurance authorization processes, post-acute care settings, and demonstrated ability to build effective working relationships with case managers and physicians.

Physical Requirements for Essential Job Qualification

Levels:

• None (No specific requirements)

• Occasionally (Less than 1/3)

• Frequently (1/3 to 2/3)

• Majority (More than 2/3)

Remain in a stationary position: Majority

Traverse or move around work location: Occasionally

Use keyboard: Frequently

Operate or use department specific equipment: None

Ascend/Descend equipment or ladder: None

Position self to accomplish the Essential Functions of the role: Occasionally

Receive and communicate information and ideas for understanding: Frequently

Transport, position, and/or exert force:

Up to 10 pounds: Occasionally

Up to 25 pounds: _____

Up to 50 pounds: _____

Up to 75 pounds: _____

More than 100 pounds: _____

Other weight: Up to___ pounds _ ____

Other: _____

Consistent with the Americans with Disabilities Act (ADA), it is the policy of Mary Free Bed Rehabilitation Hospital to provide reasonable accommodation when requested by a qualified applicant or employee with a disability, unless such accommodation would cause an undue hardship. The policy regarding requests for reasonable accommodation applies to all aspects of employment, including the application process. If reasonable accommodation is needed, please contact the Talent Acquisition team at View email address on click.appcast.io.

Mary Free Bed is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, age, genetic information, veteran status, disability or other legally protected characteristic.