RN Transitional Care Navigator: Discharge & Care Continuity

University Hospitals Pain Management; Willoughby (OH); On-site; USD 52,000 - 78,000; Part time

Job summary

University Hospitals Pain Management is seeking a Transitional Care Coordinator to streamline post-acute care planning and transition, coordinating with the patient, family, and care team to optimize outcomes.

The role focuses on assessment, discharge planning, interdepartmental collaboration, and connecting patients with community-based resources and care networks to reduce readmissions.

Responsibilities

• Completes assessment of patient’s prior functioning, supports and resources; documents plan and referrals.
• Collaborates with the multidisciplinary care team to ensure coordinated patient care.
• Provides updates to medical and nursing teams on the plan for stay, discharge, or movement to another care setting (home care, SNF, IRF, hospital at home, etc.).
• Develops, documents and implements a discharge plan aligned with patient and family goals, including length of stay and treatment plan discussions with the physician.
• Assists with recruitment, onboarding, mentoring and education of new staff.
• Focuses on readmission risk assessments and intercept programs for patients not requiring inpatient admission.
• Connects patients to care networks (PCI, ACO, Managed Care teams).

Job description

University Hospitals Pain Management is seeking a Transitional Care Coordinator to streamline post-acute care planning and transition, coordinating with the patient, family, and care team to optimize outcomes.

The role focuses on assessment, discharge planning, interdepartmental collaboration, and connecting patients with community-based resources and care networks to reduce readmissions.