Facilitates discharge planning to ensure safe transitions, effective patient flow, and high-quality care. Assesses patient clinical and psychosocial needs, identifies risk factors, and develops individualized discharge plans. Collaborates with physicians, nurses, patients, and families to coordinate care and support length of stay management and prevent readmissions. Coordinates interdisciplinary communication through care coordination rounds, complex care meetings, and discharge huddles. Facilitates meetings with patients, families, and providers to support participation in care planning and discharge decisions. Coordinates referrals to community resources and assists with advance directives and healthcare decision planning. Ensures accurate documentation and compliance with CMS, DNV, payer, and hospital regulatory requirements. Qualifications. Education:RN diploma or Bachelor's degree in Nursing required. Bachelor's or Master's degree in Social Services preferred. Experience:Two years of experience in acute care, intermediate care, or home care (or comparable setting) required. Three to five years of clinical experience in acute care, intermediate care, or home care preferred. Knowledge of community resources and agencies preferred. License(s)/ Certification(s):Current RN licensure in good standing in Iowa required; Illinois licensure required (or obtained within 30 days of hire)Basic Life Support (BLS/ CPR) certification upon hire required. ACLS certification required and maintained. Valid driver's license required when driving for work-related duties