Completes initial evaluations for transition of care needs within one day of admission and documents per policies. Reviews labs, medications, history and physical, therapy notes, test results, and progress notes. Incorporates patient and family care goals and preferences into the transition plan and communicates them to the multidisciplinary team. Discusses discharge options and post-hospital care providers with patients and families. Collaborates with the interdisciplinary team to resolve barriers to the care plan. Participates in daily multidisciplinary rounds to facilitate patient care progression. Monitors readmission risk scores and coordinates mitigation interventions. Consults social work for psychosocial needs, decision-making for patients lacking capacity, and complex cases. Assists with end-of-life conversations, living wills, advance directives, power of attorney, and community DNR. Other duties as assigned. Knowledge, Skills, and Abilities: Leadership skills [Preferred] Process and Outcome data analysis skills [Preferred] Critical thinking and problem-solving skills [Preferred] Ability to manage multiple tasks and prioritize levels of importance [Preferred] Customer service skills [Preferred] Ability to work and communicate with people of all social, economic, and cultural backgrounds; be flexible, open-minded and adaptable to change [Preferred] Effective organizational skills [Preferred] Computer proficiency with Outlook e-mail and electronic medical records [Preferred] Flexible in a complex and changing healthcare environment [Preferred]Education: Associate [Required] Bachelor's of Nursing [Preferred] Diploma Nursing [Preferred] Master's of Nursing [Preferred]Work Experience: 2 years related experience [Preferred]Licenses and Certifications: Registered Nurse (RN) [Required] Basic Life Support - CPR Cert (BLS) [Preferred] Accredited Case Manager (ACM) [Preferred] Certified Case Manager (CCM) [Preferred] Advanced Cardiac Life Support Cert (ACLS) [Preferred] Pediatric Advanced Life Support Cert (PALS) [Preferred] Trauma Nurse Course Certified (TNCC) [Preferred]Physical Requirements: (Please click the link below to view work requirements)Physical Requirements - r 9 dca 9 b. Pay Range:$15.00 - $130.00