RN Care Transition & Discharge Navigator

WVU Medicine; Morgantown (WV); On-site; USD 70,000 - 95,000; Full time

Job summary

WVU Hospitals is seeking an experienced nurse to lead comprehensive transition and discharge planning for assigned patients in Morgantown, WV. You will work with a multidisciplinary team to ensure timely, patient-centered care and smooth transitions to post-acute services.

The role requires an active RN license (state or eNLC) and at least three years of clinical experience; BSN is preferred. You will educate staff and families, coordinate referrals, and document progress according to policy.

Qualifications

• RN license current in the state where services are provided or multistate RN license via eNLC.
• Three (3) years of clinical experience.
• BSN preferred.

Responsibilities

• Plans transition/discharge for assigned patients.
• Collaborates with multidisciplinary team to facilitate discharge.
• Monitors progress and ensures care plan is patient-focused and cost-effective.
• Educates staff, physicians and patients/families on transition planning.
• Develops individualized discharge plans with physician team.
• Coordinates post-acute referrals (home health, DME, hospice, SNF, etc).
• Documents interactions and progress per policy.
• Assists with power of attorney and advance directives as needed.
• Manages resource and financial aspects including entitlements and referrals.

Skills

RN care coordination

Discharge planning

Transition management

Multidisciplinary collaboration

Education for staff/patients

Utilization management

Payer/denials awareness

Post-acute referrals

Education

RN license (state or eNLC)

BSN preferred

Job description

WVU Hospitals is seeking an experienced nurse to lead comprehensive transition and discharge planning for assigned patients in Morgantown, WV. You will work with a multidisciplinary team to ensure timely, patient-centered care and smooth transitions to post-acute services.

The role requires an active RN license (state or eNLC) and at least three years of clinical experience; BSN is preferred. You will educate staff and families, coordinate referrals, and document progress according to policy.