RN Care Transitions Specialist - Med/Surg

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

Job summary

University Hospitals in Cleveland seeks an RN Transitional Care Coordinator for the Med/Surg unit to optimize post-acute care planning and ensure smooth handoffs across care settings.

The role partners with the care team, family, and community resources to reduce readmissions and align care with patient goals. Ohio RN licensure and 1+ year acute care experience are required; Bachelor's degree is preferred.

Qualifications

• RN license in Ohio (or multi-state) is required.
• 1+ year of clinical nursing experience in acute care is required.
• Experience with utilization management, case management, post-acute transitions, and home health is preferred.

Responsibilities

• Assess patient’s prior functioning, resources, and social determinants; document comprehensive plan and referrals.
• Collaborate with the care team to coordinate discharge and care movements (home care, SNF, IRF, Hospital at Home).
• Develop and implement individualized discharge plans with patient/family goals and estimated LOS.
• Assist with recruitment, orientation, and mentoring of new staff.
• Focus on readmission risk assessment and alternative services for patients not requiring inpatient admission.
• Connect patients to PCI, ACO, and Managed Care teams.

Skills

Clinical knowledge

Payer regulations

Computer literacy

Multitasking

Autonomy

Communication

Clinical competency

Teaching skills

Professional demeanor

Education

RN license (Ohio)

Bachelor’s degree (preferred)

Job description

University Hospitals in Cleveland seeks an RN Transitional Care Coordinator for the Med/Surg unit to optimize post-acute care planning and ensure smooth handoffs across care settings.

The role partners with the care team, family, and community resources to reduce readmissions and align care with patient goals. Ohio RN licensure and 1+ year acute care experience are required; Bachelor's degree is preferred.