RN - Clinical Transition Specialist

Responsible for managing patient outcomes during acute hospitalization, ensuring proactive assessments, ongoing evaluations, and seamless discharge planning. Facilitates safe transitions from hospital to appropriate care settings, utilizing case management components: assessment, coordination, monitoring, implementation, and evaluation. Key Responsibilities Act as a liaison with patients, families, and physicians to determine post-discharge care needs. Coordinate inpatient to post-hospital care, ensuring timely and appropriate services. Document and evaluate care plans, utilization issues, and patient progress. Initiate pre- and post-hospital interventions, referrals, and assessments for discharge needs. Collaborate with interdisciplinary teams to meet goals related to length of stay and readmission reduction. Assess patients' post-discharge requirements, arrange services like DME, home care, hospice, and transportation. Participate in daily rounds, department work groups, and follow-up appointments to ensure continuity of care. Obtain prior authorizations, review for utilization, and address denials as needed. Perform nursing activities including assessment, care planning, monitoring, and education. Qualifications & Skills Licensed Registered Nurse (RN) with a college diploma in nursing. Certifications: BLS (within 30 days), ACM (within 3 years). Strong communication, coordination, and interdisciplinary collaboration skills. Experience in case management, discharge planning, or related healthcare roles preferred. Ability to evaluate care effectiveness and facilitate patient-centered outcomes. #J-18808-Ljbffr