RN - Clinical Transitions Specialist

Assess patients for post-discharge needs within 24-48 hours of admission and ongoing throughout the stay. Coordinate transitions from inpatient care to post-hospital settings by acting as a liaison with patients, families, and physicians to determine next levels of care. Manage length of stay, track avoidable days, and evaluate plan of care effectiveness to reduce readmission risk. Initiate interventions pre-hospital, in-hospital, and post-hospital, including arranging DME, home care, and hospice services. Document case management activities in utilization review software and participate in multidisciplinary rounds. Conduct case review presentations to educate peers on challenging cases.