RN Transitional Care Coordinator: Post-Acute Discharge

University Hospitals; Parma (OH); On-site; USD 65,000 - 90,000; Full time

Job summary

University Hospitals in Parma, OH is seeking an RN Transitional Care Coordinator to optimize post-acute care transitions and coordinate care across teams. The role emphasizes comprehensive assessments, discharge planning, and collaboration with patients, families, and providers.

Required 1+ years of acute care nursing; RN licensure. Bachelor's degree preferred. This on-site position involves coordinating with PCI/ACO teams to reduce readmissions and improve patient experience.

Qualifications

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

Responsibilities

• Completes assessment including patient’s prior functioning, connection to resources, existing supports, and social determinants of health; documents plan and referrals.
• Collaborates with the care team using a multidisciplinary approach and provides updates to the medical and nursing teams.
• Develops and implements a discharge plan aligned with patient and family goals; discusses estimated LOS and discharge plan with the medical team.
• Develops and documents a post-acute care plan; coordinates transitions to home care, SNF, IRF, or Hospital at Home.
• Assists with recruitment, orientation, and mentoring of new staff.
• Focuses on readmission assessments and intercept programs for patients not requiring inpatient admission.
• Connects patients to PCI, ACO, and Managed Care teams.

Skills

Clinical knowledge

Payer regulations

Computer skills

Multitasking

Autonomy

Communication

Teaching

Professional demeanor

Education

RN licensure

Bachelor's degree (preferred)

Job description

University Hospitals in Parma, OH is seeking an RN Transitional Care Coordinator to optimize post-acute care transitions and coordinate care across teams. The role emphasizes comprehensive assessments, discharge planning, and collaboration with patients, families, and providers.

Required 1+ years of acute care nursing; RN licensure. Bachelor's degree preferred. This on-site position involves coordinating with PCI/ACO teams to reduce readmissions and improve patient experience.