RN Care Transitions Navigator — Post-Acute Discharge

University Hospitals; Cleveland (OH); On-site; USD 70,000 - 90,000; Full time

Job summary

University Hospitals in Cleveland is seeking a Registered Nurse to serve as a Transitional Care Coordinator at Seidman Cancer Center. You will assess patients, plan post-acute care, and coordinate referrals to home health, SNF, or other facilities to ensure safe transitions.

The role emphasizes collaboration with the care team, discharge planning aligned with patient goals, staff development, and readmission prevention through targeted interventions and care connections with PCI, ACO, and

Qualifications

• Graduate of an accredited school of nursing (Required).
• Bachelor's Degree (Preferred).
• 1+ years clinical nursing experience (acute care) (Required).
• Experience with case management and post-acute transitions (Preferred).

Responsibilities

• Completes assessment including patient’s previous level of functioning and resources; documents plan and referrals.
• Collaborates with the multidisciplinary team to coordinate care.
• Provides updates to medical team about plan of care, discharge, or movement to alternate site.
• Develops and documents discharge plans aligned with patient and family goals.
• Assists with recruitment and orientation/mentoring of new staff.
• Focuses on readmission assessments and intercept programs for non-admitted patients.
• Connects patients to PCI, ACO, Managed Care teams.

Skills

Clinical knowledge

Medicare/Medicaid regulations

Computer literacy

Multi-tasking

Autonomy

Communication skills

Clinical competency maintenance

Teaching skills

Professional demeanor

Education

RN - Registered Nurse

Bachelor's degree (Preferred)

Job description

University Hospitals in Cleveland is seeking a Registered Nurse to serve as a Transitional Care Coordinator at Seidman Cancer Center. You will assess patients, plan post-acute care, and coordinate referrals to home health, SNF, or other facilities to ensure safe transitions.

The role emphasizes collaboration with the care team, discharge planning aligned with patient goals, staff development, and readmission prevention through targeted interventions and care connections with PCI, ACO, and