Work From Home - Registered Nurse

Mission Control RN Patient Placement & Transfer Coordination
The Mission Control RN Readmissions & Transitions of Care serves as a critical system-level resource focused on preventing avoidable hospital readmissions through proactive patient placement, transfer coordination, and post?acute care alignment. This role partners closely with hospitals, physicians, care management teams, post?acute providers, and community agencies to ensure patients are transitioned to the right level of care, at the right time, with the right supports to promote safe discharges and reduce return hospitalizations.
acuity environment and demonstrates strong clinical judgment, operational coordination skills, and a deep understanding of drivers of readmissions, care transitions, and continuity of care.
acute referrals with a primary focus on reducing avoidable readmissions and supporting safe, sustainable transitions of care.
risk conditions to determine the most appropriate post?inpatient, observation, SNF, LTACH, behavioral health, home?based services).
Utilize clinical judgment, acuity tools, and readmissions risk indicators (e.g., Partner with hospital care management, nursing leadership, and physicians to address barriers to discharge and placement that increase readmission risk.
time system capacity, community census data, and post?risk readmission populations.
Develop and support contingency placement strategies for patients at risk for return admissions due to limited resources, behavioral health needs, or complex medical conditions.
risk patients requiring specialized placement or services.
Serve as a centralized coordination point between referring facilities, emergency departments, inpatient teams, care managers, post?acute providers, and community partners.
Collaborate closely with behavioral health and psychiatric facilities to support appropriate placement of patients with co?occurring medical and behavioral health needs.
Facilitate timely, professional communication with physicians and leadership to support decisions that align with readmissions reduction strategies.
Coordinate with Patient Access and Patient Financial Services to align insurance authorization and financial clearance with discharge and placement timing.
Accurately document all placement, transfer, and readmissions?related coordination activities in electronic systems to support patient safety, compliance, and performance monitoring.
Ensure all clinical, legal, and transfer documentation is complete, accurate, and compliant prior to patient movement.
Review electronic communications regularly to remain current on readmissions initiatives, workflow updates, and regulatory requirements.
Support onboarding, mentoring, and education of team members related to readmissions prevention, transitions of care, and placement best practices.
Participate in departmental and system initiatives focused on reducing readmissions, improving care transitions, and strengthening community partnerships.
Maintain ongoing knowledge of readmissions drivers, regulatory requirements, and evidence?based transition?of?care practices.
Proficiency with electronic medical records and real-time electronic documentation.
Working knowledge of patient throughput, transfer center operations, and healthcare compliance standards.
Associate Degree in Nursing (ADN)

Bachelor of Science in Nursing (BSN)

Minimum of 2 years of acute care clinical experience

1+ years of readmissions, care management, or transitions?of?care experience preferred.

• 5+ years of RN experience in Med?Surg, Emergency Department, or critical care settings preferred.
• Behavioral Health Patient Placement experience
• Quality Experience

Certified Emergency Nurse (CEN)
Adult Clinical Nurse Specialist (ACNS-BC)
Licensed Mental Health Counselor (LMHC)