Care Transition RN MHO in South Bend, Indiana at Beacon Health System

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, VALUES and SERVICE GOALS

• 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 highquality, 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 nextday priorities
• Coordinating care among multiple physicians and consulting services involved in a patient’s hospitalization to promote timely decisionmaking
• 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 followup 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

Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by:

• Completing other jobrelated duties and special projects as assigned

Associate complies with the following organizational requirements:

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains 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.

Commitment to Beacon's six-point Operating System, referred to as The Beacon Way:

• Leverage innovation everywhere.
• Cultivate human talent.
• Embrace performance improvement.
• Build greatness through accountability.
• Use information to improve and advance.
• Communicate clearly and continuously.

Education and Experience

• Current license to practice as a Registered Nurse in Indiana required
• Minimum of three years of acute care hospital experience required
• Experience in care coordination, throughput, case management collaboration, or utilization review preferred

Knowledge & Skills

• Strong understanding of inpatient clinical workflows, discharge processes, and care transitions
• Demonstrated ability to identify and resolve barriers impacting patient progression and length of stay
• Strong interpersonal and communication skills with the ability to work effectively across disciplines
• Ability to prioritize competing demands in a fastpaced, highacuity environment
• Proficiency in electronic health records (EHRs) and clinical documentation workflows
• Familiarity with CMS guidelines, payer requirements, and regulatory standards impacting discharge and LOS preferred
• Experience with Oracle/Cerner or similar EHR platforms preferred

Working Conditions

• Works in a patient care environment requiring physical exertion, frequent changes in job demands, and possible exposure to biohazards
• Requires schedule flexibility due to hospital operations occurring 24 hours per day, 7 days per week
• At risk for occupational exposure to bloodborne pathogens

Physical Demands

• Requires the physical ability and stamina to perform the essential functions of the position