RN Care Transition Navigator

University Hospitals; Parma (OH); On-site; USD 65,000 - 85,000; Full time

Job summary

University Hospitals in Parma, OH is seeking an RN Transitional Care Coordinator to optimize patient transitions to the next site of care and to manage post-acute care planning.

The role collaborates with the care team, patients, and families to develop discharge plans, address barriers, and arrange referrals for home health, SNF, IRF, or hospital-at-home options while emphasizing readmission prevention and PHI compliance.

Qualifications

• Graduate of an accredited school of nursing (Required).
• 1+ years clinical nursing experience in acute care (Required).
• Experience with utilization and case management preferred.

Responsibilities

• Assesses patient function and resource connections; documents a comprehensive plan.
• Collaborates with the multidisciplinary team to coordinate care.
• Keeps medical team updated on discharge plans and care transitions.
• Develops discharge plans aligned with patient/family goals and LOS.
• Supports recruitment and orientation of new staff.
• Focuses on readmission reduction and alternate care pathways.
• Connects patients to PCI, ACO, and managed care resources.
• Performs other duties, ensures PHI security and policy adherence.

Skills

Clinical knowledge

Medicare/Medicaid knowledge

Computer competency

Multitasking

Autonomy

Effective communication

Teaching skills

PHI compliance

Education

RN licensure

Accredited nursing program graduate

Bachelor's degree (preferred)

Job description

University Hospitals in Parma, OH is seeking an RN Transitional Care Coordinator to optimize patient transitions to the next site of care and to manage post-acute care planning.

The role collaborates with the care team, patients, and families to develop discharge plans, address barriers, and arrange referrals for home health, SNF, IRF, or hospital-at-home options while emphasizing readmission prevention and PHI compliance.