Care Transitions Nurse (RN)

Mary Free Bed Rehabilitation Hospital•Grand Rapids, MI

3d•Onsite

About The Position

The Care Transitions Nurse is a registered nurse responsible for supporting high-risk patients during the transition from the inpatient acute rehabilitation hospital to home or other care settings. This role focuses on reducing avoidable 30-day readmissions by conducting timely post-discharge outreach, identifying and addressing clinical and social barriers, reinforcing discharge instructions, and providing care coordination that is patient-centered and focused on safety. The Care Transitions Nurse serves as a liaison between the patient, healthcare team, and community resources. The nurse works collaboratively with the interprofessional team to decrease hospital readmission rates and improve patient satisfaction following discharge.

Requirements

Registered nurse in the state of Michigan.
Current Basic Life Support (BLS) certification
Associate’s degree in nursing is required.
5 years of experience as an RN, preferred experience in a rehabilitation or acute care setting.
Strong critical thinking, decision-making, delegation, and leadership skills are required to work as an RN in the Nursing Department at MFB.
Time management and organizational skills are very important, as well as effective written and verbal communication skills.
Must be able to work effectively under time requirements and deadlines, problem-solve when facing unexpected issues, handle interruptions, and prioritize effectively.
Sense of urgency, collaborative team style, and ability to quickly adapt to changes in priorities with strong decision-making skills.
Excellent analysis and decision-making skills with ability to interpret clinical and analytical assessments
Ability to multi-task for timely project completions.
Effective written and verbal communication skills.
Information-management skills and ability to interpret, communicate, and present data.
Ability to work independently with critical thinking skills when assessing patient needs.
Strong knowledge of acute care and post-acute services and their differences
Excellent communication and presentation skills
Excellent customer relations skills
Impeccable time management skills
Demonstrated results orientated

Nice To Haves

All newly hired staff will be required to become a Certified Rehabilitation Registered Nurse (CRRN) by their 3rd anniversary with Mary Free Bed. Mary Free Bed will fund training and certification towards CRRN certification.
Bachelor’s degree preferred.
Certification as a Registered Rehabilitation Nurse is preferred and will be encouraged for all MFB RNs.
Understanding of insurance authorization processes, post-acute care settings, and demonstrated ability to build effective working relationships with case managers and physicians.

Responsibilities

Provide patient care, treatment, and services within the scope of their license, certification or registration and as required by Federal and State laws and regulations.
Promote a culture of safety for all patients served by adhering to all applicable department policies and procedures.
Demonstrates understanding and actively contributes to patient safety initiatives.
Monitor assigned post-discharge patients across the continuum of care; identify and notify the appropriate care team of any readmissions, including known contributing factors.
Document all relevant information to support readmission tracking and analysis.
Conduct timely post-discharge follow-up calls and proactively identify, address, and resolve clinical, social, and system-related barriers to recovery.
Collaborate with post-acute care providers, community agencies, and interdisciplinary teams to coordinate services and secure necessary resources for patients, families, and caregivers.
Maintain accurate tracking logs and collect performance data as assigned; partner with acute and post-acute providers to identify and mitigate barriers to safe, effective, and timely transitions of care.
Participate in 30-day readmission reduction initiatives, task forces, and quality committees as assigned
Collaborate with quality and operational teams to design, implement, and evaluate process improvements that enhance care transitions and reduce readmissions
Provide timely feedback to leadership regarding program performance, opportunities for improvement, and barriers impacting patient outcomes
Demonstrate clinical expertise, care coordination, and effective communication to support patients and families throughout the continuum of care.
Perform other duties as assigned
Demonstrate excellent customer service and standards of behaviors as well as encourages, coaches, and monitors the same in team members.
This individual should consistently promote teamwork and direct communication with co-workers and deal discretely and sensitively with confidential information.
Contribute by identifying problems and seeking solutions.
Promote patient/family satisfaction where possible; participates in departmental efforts to monitor and report customer service.