RN Care Transitions I-LGH-FT/Days

Care Transitions Nurse

Care transitions nurse is responsible for the clinical aspects of determining the appropriate discharge plan for patients in the acute care setting. This member of the care transition team will be responsible for facilitating and coordinating a safe appropriate discharge plan while meeting the patient's individual needs as well as state and federal regulations. This position works collaboratively with multiple other disciplines throughout the organization and community.

Responsibilities

Coordinates patient care from admission to discharge. Conducts a comprehensive clinical patient/family assessment to ensure appropriate referrals. Identifies any barriers and provides clarity to determine realistic goals for the treatment plan. Demonstrates knowledge of the patient's diagnosis/prognosis care needs and outcome goals of the treatment/care plan. Identifies short-term goal within a time frames for achieved goals appropriate to the patient and family. Patients have a discharge disposition assessed and plan initiated within hours of admission of scheduled workdays. Initiates and implements treatment plan modification through monitoring and re-evaluation to accommodate changes in treatment or progress. Communicates appropriate information between physicians, nursing units, administration and other disciplines to facilitate care transitions to ensure proper patient flow through the hospital system. Collaborates with other departments to ensure customer satisfaction and coordinate appropriate patient care. Coordinates daily patient care with other members of the interdisciplinary team. Demonstrates documentation to substantiate assessment planning implementing and evaluating of discharge plan in a clear concise organized timely manner. Identifies barriers to timely patient discharge and facilitates resolution of the barriers and appropriately reports non-acute days. Coordinates and provides hand off to other post-acute providers. Contributes to the overall LOS. Follows CMS guidelines with regards to observation notice (OBN) and inpatient notice (IMM). May perform other duties as assigned or requested and job specification can be modified or updated at any time.

Qualifications

Required Education: Graduate of an accredited Nursing Program. Preferred Education: Bachelors of Science Degree in Nursing (BSN). Required Experience: Three (3) years of experience in acute care nursing. Computer skills as well as excellent communication and the ability to work collaboratively with other disciplines. Preferred Experience: Working knowledge of D/C planning, LTC, or Medicare regulations. Required Certifications and Licensures: Active license as a registered nurse in Virginia or hold a current multistate licensure privilege as a registered nurse. Hold a current, active American Heart Association Basic Life Support (AHA BLS) course completion card. Preferred Certifications and Licensures: ACMA Certification. Salary Range: $31.05 - $48.13 / Hour.

Job Info

• Job Identification 20289
• Job Category Nursing Professional
• Posting Date 06/10/2026, 12:50 PM
• Locations 1901 Tate Springs Rd, Lynchburg, VA, 24501, US