Care Transitions Nurse (RN)Day Shift (United States of America)
Employment Type
Full-time - Days
Schedule
Monday - Friday, 8-hour days
Compensation
Salaried/Exempt starting: $76,000
Primary Location
Main Hospital - Grand Rapids, MI
Department Name
Inpatient Acute Rehab
Other Benefits
Annual Merit Increases, Health Insurance (Medical, Dental, Vision,) PTO, Holiday Pay, PSLF Eligible, Tuition Reimbursement
Summary
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 .
Essential Job Responsibilities
Clinical Required : 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.
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.
E nsuring a welcoming experience for all we serve, regardless of origin, race, religion, disability, sexual orientation or socioeconomic status.
Customer Service Responsibilities
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 .
Responsibilities in Quality Improvement
Contribute by identifying problems and seeking solutions. Promote patient/family satisfaction where possible; participates in departmental efforts to monitor and report customer service.
Essential Job Qualifications
Strong critical thinking, decision-making, delegation, and leadership skills are required to work as an RN in the Nursing Department at MFB.
Must be able to work effectively under time requirements and deadlines, problem-solve when facing unexpected issues, handle interruptions, and prioritize effectively.
Preferred Job Qualifications
Physical Requirements for Essential Job Qualification
Remain in a stationary position: Majority
Traverse or move around work location: Occasionally
Operate or use department specific equipment: None
Ascend/Descend equipment or ladder : None
Position self to accomplish the Essential Functions of the role : Occasionally
Receive and communicate information and ideas for understanding: Frequently
Transport, position, and/or exert force:
Up to 10 pounds: Occasionally
More than 100 pounds : _____
Other weight: Up to___ pounds _ ____
Consistent with the Americans with Disabilities Act (ADA), it is the policy of Mary Free Bed Rehabilitation Hospital to provide reasonable accommodation when requested by a qualified applicant or employee with a disability, unless such accommodation would cause an undue hardship. The policy regarding requests for reasonable accommodation applies to all aspects of employment, including the application process. If reasonable accommodation is needed, please contact the Talent Acquisition team at [email protected] .
Mary Free Bed is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, age, genetic information, veteran status, disability or other legally protected characteristic .
