Care Transitions Nurse (RN)

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.   ​ 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   ​ We’ll   embrace all people by :     ​ ​ T reating everyone with dignity and respect.     ​ ​ O pening more doors to opportunity for others to succeed.     ​ ​ G rowing talent and people.     ​ ​ E nsuring a welcoming experience for all we serve, regardless of origin, race, religion, disability, sexual   orientation   or socioeconomic status.       ​ ​ T aking action   against discrimination.     ​ ​ H onoring our differences and how we collaborate.     ​ ​ E ducating staff,   patients   and the communities we care for.     ​ ​ R estoring hope and   freedom,   together .   ​   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   Licensure:     Registered nurse in the state of Michigan.     CRRN Requirement:   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.     Current Basic Life Support (BLS) certification     Education:   Associate’s degree in nursing is   required .  Bachelor’s degree preferred.  Certification as a Registered Rehabilitation Nurse is preferred and will be encouraged for all MFB RNs.       Experience:       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