RN - Clinical Transition Specialist

Role Overview: Responsible for managing patient outcomes during acute hospitalization, ensuring proactive assessments, ongoing evaluations, and seamless discharge planning. Facilitates safe transitions from hospital to appropriate care settings, utilizing case management components: assessment, coordination, monitoring, implementation, and evaluation. Key Responsibilities Act as a liaison with patients, families, and physicians to determine post-discharge care needs.Coordinate inpatient to post-hospital care, ensuring timely and appropriate services.Document and evaluate care plans, utilization issues, and patient progress.Initiate pre- and post-hospital interventions, referrals, and assessments for discharge needs.Collaborate with interdisciplinary teams to meet goals related to length of stay and readmission reduction.Assess patients' post-discharge requirements, arrange services like DME, home care, hospice, and transportation.Participate in daily rounds, department work groups, and follow-up appointments to ensure continuity of care.Obtain prior authorizations, review for utilization, and address denials as needed.Perform nursing activities including assessment, care planning, monitoring, and education. Qualifications & Skills Licensed Registered Nurse (RN) with a college diploma in nursing.Certifications: BLS (within 30 days), ACM (within 3 years).Strong communication, coordination, and interdisciplinary collaboration skills.Experience in case management, discharge planning, or related healthcare roles preferred.Ability to evaluate care effectiveness and facilitate patient-centered outcomes.