Care Transition RN MHO

Responsibilities

• Facilitates multidisciplinary walking rounds on assigned unit(s), ensuring clear daily plans of care and anticipated discharge timelines
• Attends and actively participates in the daily Barrier Review meeting, identifying and escalating unresolved barriers impacting length of stay
• Attends case management afternoon review meetings to coordinate discharge planning and align next-day priorities
• Collaborates with physicians and consulting services involved in a patient’s hospitalization to promote timely decision-making
• Follows up on pending laboratory results, diagnostic tests, and procedures to prevent delays in clinical progression
• Coordinates care among multiple physicians and consulting services involved in a patient’s hospitalization to promote timely decision-making
• Collaborates with ancillary departments to prioritize diagnostic services (including but not limited to echocardiograms, MRI, EEG) based on LOS impact
• Affords expediting operating room time slots when clinically appropriate, or facilitates transition of procedures to outpatient settings when indicated
• Collaborates with interventional radiology and other procedural departments to prioritize patients whose length of stay is impacted by procedural delays
• Supports earlier engagement of specialty consultants when delays are identified, including assisting teams in navigating access and scheduling barriers
• Follows up on incidental findings identified during hospitalization (e.g., pulmonary nodules) to ensure appropriate outpatient follow-up appointments are scheduled prior to discharge
• Partners with case management, nursing, and providers to ensure discharge plans are executable and barriers are resolved proactively
• Follows up on recently discharged patients to ensure discharge orders are completed in the electronic health record and patient rooms are released for environmental services and bed turnover

Qualifications

• Current license to practice as a Registered Nurse in Indiana required
• Minimum of three years of acute care hospital experience required
• Experience in care coordination, throughput, case management collaboration, or utilization review preferred
• Strong understanding of inpatient clinical workflows, discharge processes, and care transitions
• Demonstrated ability to identify and resolve barriers impacting patient progression and length of stay
• Strong interpersonal and communication skills with the ability to work effectively across disciplines
• Ability to prioritize competing demands in a fast-paced, high-acuity environment
• Proficiency in electronic health records (EHRs) and clinical documentation workflows
• Familiarity with CMS guidelines, payer requirements, and regulatory standards impacting discharge and LOS preferred
• Experience with Oracle/Cerner or similar EHR platforms preferred