RN Transitional Care Coordinator-Seidman Cancer Center

%3Cb%3EA Brief Overview%3C/b%3E%3C/br%3E%3Cp%3EEnsures appropriate next site of care for patient using evidence-based decision support tools. The Transitional Care Coordinator (TCC) collaborates with all members of a patient%27s care team, including the family and support systems, to enhance the patient experience and ready the patient for the next site of care. The TCC develops and modifies a patient%27s post-acute care plan, identifies any barriers for follow-up care, brings in specialty in-hospital consultations as needed (nutrition, social work, therapy, etc.), and helps facilitate the provider hand-off to the next level of care.%3C/p%3E%3Cb%3EWhat You Will Do%3C/b%3E%3C/br%3E%3Cul%3E%3Cli%3ECompletes assessment including patient’s previous level of functioning, connection to hospital and community based resources, existing supports, SDOH. Documents comprehensive plan and facilitates necessary referrals as needed. 30%%3C/li%3E%3Cli%3ECommunicates and collaborates with the larger team with a multidisciplinary approach. 10%%3C/li%3E%3Cli%3EProvides updates to medical team and nursing of patients plan of care and plan for the stay, discharge or movement to alternative site including but not limited to home care, SNF, IRF, Hospital at Home, or other alternative facility. (20%).%3C/li%3E%3Cli%3EDevelops, documents and implements a discharge plan consistent with individual patient needs and with patient and family goals. Develops plans with attention to individual patient and family goals. Discusses estimated length of stay, treatment plan and discharge plan with attending physician and/or medical team. 30%%3C/li%3E%3Cli%3EAssist with recruitment, and orientation/mentoring/education of new staff.%3C/li%3E%3Cli%3EFocus on readmission assessments and intercept programs/alternative services for patients not requiring an admit status (inpatient and obs).%3C/li%3E%3Cli%3EConnecting patients to care (PCI, ACO, Managed Care teams).%3C/li%3E%3C/ul%3E%3Cb%3EAdditional Responsibilities%3C/b%3E%3C/br%3E%3Cul%3E%3Cli%3EPerforms other duties as assigned.%3C/li%3E%3Cli%3EComplies with all policies and standards.%3C/li%3E%3Cli%3EFor specific duties and responsibilities, refer to documentation provided by the department during orientation.%3C/li%3E%3Cli%3EMust abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.%3C/li%3E%3C/ul%3E
%3Cb%3EEducation%3C/b%3E%3C/br%3E%3Cul%3E%3Cli%3E Graduate of an accredited school of nursing (Required) and %3C/li%3E%3Cli%3EBachelor%27s Degree (Preferred) %3C/li%3E%3C/ul%3E%3Cb%3EWork Experience%3C/b%3E%3C/br%3E%3Cul%3E%3Cli%3E1+ years clinical nursing experience (acute care), (Required) and %3C/li%3E%3Cli%3E Experience and knowledge of utilization management, case management, post-acute transitions, and home health (Preferred) %3C/li%3E%3C/ul%3E%3Cb%3EKnowledge, Skills, %26amp; Abilities%3C/b%3E%3C/br%3E%3Cul%3E%3Cli%3E Sound clinical knowledge base (Required proficiency) %3C/li%3E%3Cli%3E Knowledge of Medicare, Medicaid and commercial payer regulations (Required proficiency) %3C/li%3E%3Cli%3E Computer competency (Required proficiency) %3C/li%3E%3Cli%3E Multi-tasks and prioritizes work (Required proficiency) %3C/li%3E%3Cli%3E Works autonomously (Required proficiency) %3C/li%3E%3Cli%3E Communicates effectively with persons of various backgrounds (oral and written) (Required proficiency) %3C/li%3E%3Cli%3E Maintain clinical competency regarding health care delivery/regulatory requirements. (Required proficiency) %3C/li%3E%3Cli%3E Teaching skills (Required proficiency) %3C/li%3E%3Cli%3E Maintains a calm, professional demeanor when dealing with internal and external contacts (Required proficiency) %3C/li%3E%3C/ul%3E%3Cb%3ELicenses and Certifications%3C/b%3E%3C/br%3E%3Cul%3E%3Cli%3ERegistered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire) %3C/li%3E%3Cli%3E CM certification (Preferred) %3C/li%3E%3C/ul%3E%3Cb%3EPhysical Demands%3C/b%3E%3C/br%3E%3Cul%3E%3Cli%3EStanding Frequently %3C/li%3E%3Cli%3EWalking Frequently %3C/li%3E%3Cli%3ESitting Rarely %3C/li%3E%3Cli%3ELifting Frequently up to 50 lbs %3C/li%3E%3Cli%3ECarrying Frequently up to 50 lbs %3C/li%3E%3Cli%3EPushing Frequently up to 50 lbs %3C/li%3E%3Cli%3EPulling Frequently up to 50 lbs %3C/li%3E%3Cli%3EClimbing Occasionally up to 50 lbs %3C/li%3E%3Cli%3EBalancing Occasionally %3C/li%3E%3Cli%3EStooping Frequently %3C/li%3E%3Cli%3EKneeling Frequently %3C/li%3E%3Cli%3ECrouching Frequently %3C/li%3E%3Cli%3ECrawling Occasionally %3C/li%3E%3Cli%3EReaching Frequently %3C/li%3E%3Cli%3EHandling Frequently %3C/li%3E%3Cli%3EGrasping Frequently %3C/li%3E%3Cli%3EFeeling Constantly %3C/li%3E%3Cli%3ETalking Constantly %3C/li%3E%3Cli%3EHearing Constantly %3C/li%3E%3Cli%3ERepetitive Motions Constantly %3C/li%3E%3Cli%3EEye/Hand/Foot Coordination Constantly %3C/li%3E%3C/ul%3E%3Cb%3ETravel Requirements%3C/b%3E%3C/br%3E%3Cul%3E%3Cli%3E10% %3C/li%3E%3C/ul%3E

Job Details
Primary Location: United States-Ohio-Cleveland
Work Locations: 11100 Euclid Avenue, Cleveland, 44106
Job: Nurse – Non-Direct Patient Care
Organization: CMC_Operations
Schedule: Full-time
Employee Status: Regular
Shift: Days
Job Type: Standard
Job Level: Professional
Travel: Yes, 10 % of the Time
Remote Work: No
Job Posting: Sep 3, 2026, 10:25:12 PM