Care Transitions Nurse; RN

Summary

Compensation:
Salaried/Exempt starting: $76,000.

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 care coordination and safety.

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

• Provide patient care, treatment, and services within the scope of the RN license and applicable state and federal regulations.
• Promote a culture of safety by adhering to department policies, participating in patient safety initiatives, and supporting the safety of all patients served.
• Monitor assigned post‑discharge patients across the continuum of care, identify readmission contributors, and notify the appropriate care team.
• Document all relevant information to support readmission tracking and analysis.
• Conduct timely post‑discharge follow‑up calls, 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; 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, promote teamwork, and handle confidential information with discretion and sensitivity.
• Contribute by identifying problems, seeking solutions, and promoting patient/family satisfaction in departmental efforts.

• Licensure:
  Registered Nurse (RN) in the state of Michigan.
• Certification:
  All newly hired staff must become a Certified Rehabilitation Registered Nurse (CRRN) by their third anniversary;
  Mary Free Bed will fund training and certification.
• BLS certification required.
• Education:
  
  Associate’s degree in nursing required;
  Bachelor’s degree preferred.
• Preferred:
  Certification as a Registered Rehabilitation Nurse; encouraged for all MFB RNs.
• Experience:
  
  Five years as an RN, preferably in rehabilitation or acute care setting.
• Skills:
  
  Strong critical thinking, decision‑making, delegation, and leadership; effective time‑management and organizational skills; excellent written and verbal communication; ability to work effectively under time constraints and prioritize tasks.
• Knowledge:
  Acute care and post‑acute services differences; insurance authorization processes and post‑acute care settings.
• Customer relations skills and a collaborative team style with the ability to adapt quickly to changing priorities.

No specific physical requirements.

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. Consistent with the Americans with Disabilities Act (ADA), Mary Free Bed Rehabilitation Hospital provides reasonable accommodation when requested by a qualified applicant or employee with a disability, unless such accommodation would cause undue hardship.