Care Transition RN MHO

Reports to the Length of Stay Manager. The Care Transition Nurse is responsible for actively facilitating timely, safe, and efficient patient progression toward discharge by identifying, addressing, and escalating barriers to care transitions. This role functions as a hands‑on clinical coordinator, working in real time with physicians, nursing, case management, ancillary departments, and procedural areas to expedite diagnostics, procedures, consults, and discharge readiness.

The Care Transition Nurse supports hospital length‑of‑stay (LOS) optimization by ensuring plans of care move forward without avoidable delay while maintaining high standards of patient safety and quality.

• Mission:
  We deliver outstanding care, inspire health, and connect with heart.
• Values:
  Trust. Respect. Integrity. Compassion.
• Service goals:
  Personally connect. Keep everyone informed. Be on their team.

Facilitates care transitions and discharge readiness to ensure high‑quality, efficient patient flow by:

• Facilitating multidisciplinary walking rounds on assigned unit(s), ensuring clear daily plans of care and anticipated discharge timelines.
• Attending and actively participating in the daily Barrier Review meeting, identifying and escalating unresolved barriers impacting length of stay.
• Attending case‑management afternoon review meetings to coordinate discharge planning and align next‑day priorities.
• Coordinating care among multiple physicians and consulting services involved in a patient’s hospitalization to promote timely decision‑making.
• Following up on pending laboratory results, diagnostic tests, and procedures to prevent delays in clinical progression.
• Prioritizing and coordinating diagnostic services (including but not limited to echocardiograms, MRI, EEG) in collaboration with ancillary departments based on LOS impact.
• Assisting with expediting operating room time slots when clinically appropriate, or facilitating transition of procedures to outpatient settings when indicated.
• Collaborating with interventional radiology and other procedural departments to prioritize patients whose length of stay is impacted by procedural delays.
• Supporting earlier engagement of specialty consultants when delays are identified, including assisting teams in navigating access and scheduling barriers.
• Following up on incidental findings identified during hospitalization (e.g., pulmonary nodules) to ensure appropriate outpatient follow‑up appointments are scheduled prior to discharge.
• Partnering with case management, nursing, and providers to ensure discharge plans are executable and barriers are resolved proactively.
• Following up on recently discharged patients to ensure discharge orders are completed in the electronic health record and patient rooms are released for environmental services and bed turnover.

• Completing other job‑related duties and special projects as assigned.

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department‑specific education within established time frames.
• Completes annual employee health requirements within established time frames.
• M sustains license/certification, registration in good standing throughout fiscal year.
• Direct patient‑care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

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