RN Care Transition Specialist

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

Job summary

University Hospitals is seeking a Transitional Care Coordinator to work with the patient’s care team, including families, to optimize post-acute planning, readiness for the next site of care, and to remove barriers to follow-up care.

You will assess functioning, resources, and social determinants, develop and modify discharge plans, coordinate with nursing and medical teams, and facilitate hand-offs to home, SNF, IRF, or other facilities, while protecting PHI and ensuring patient-centered care.

Qualifications

• Assessment of patient functioning, resources, and social needs.
• Ability to work with a multidisciplinary care team.
• Develop and document post-acute care plans.
• Discharge planning aligned with patient and family goals.
• PHI handling and compliance with UH policies.

Responsibilities

• Completes assessment including prior functioning, resources, supports, and SDOH; documents plan and referrals.
• Communicates and collaborates with the multidisciplinary care team.
• Provides updates to medical/nursing teams on care and discharge plans.
• Develops and documents discharge plans with patient and family goals.
• Assists with recruitment, orientation, and mentoring of new staff.
• Focus on readmission risk assessment and intercept programs.
• Connects patients to PCI/ACO/Managed Care teams.

Skills

Care coordination

Discharge planning

Multidisciplinary collaboration

Family-centered care

Job description

University Hospitals is seeking a Transitional Care Coordinator to work with the patient’s care team, including families, to optimize post-acute planning, readiness for the next site of care, and to remove barriers to follow-up care.

You will assess functioning, resources, and social determinants, develop and modify discharge plans, coordinate with nursing and medical teams, and facilitate hand-offs to home, SNF, IRF, or other facilities, while protecting PHI and ensuring patient-centered care.