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:
Inpatient Acute Rehab

Other Benefits:
Annual Merit Increases, Health Insurance (Medical, Dental, Vision), PTO, Holiday Pay, PSLF Eligible, Tuition Reimbursement

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 patient‑centered safety‑focused care coordination.

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.

• Clinical
  
  Required:
  
  Provide patient care, treatment, and services within scope of 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 and encourage, coach, and monitor the same in team members. Consistently promote teamwork and direct communication with co‑workers and handle confidential information discretely and sensitively.

Contribute by identifying problems and seeking solutions. Promote patient/family satisfaction when possible; participate in departmental efforts to monitor and report customer service.

• 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 toward 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…