Care Transitions Nurse

Methodist Hospital, part of SA Health, is a leading healthcare provider in San Antonio, delivering comprehensive services from emergency care to specialized surgery. If you would like to know a bit more about this opportunity, or are considering applying, then please read the following job information. We are seeking an experienced Clinical Transitional Care Registered Nurse to support patients as they move between acute care and home or other care settings. In this role, you will coordinate discharge planning, provide patient and family education, and collaborate with multidisciplinary teams to ensure continuity of care. Our supportive, inclusive culture emphasizes teamwork, innovation, and dedication to patient-centered care. We offer competitive salaries, comprehensive benefits, and robust professional growth opportunities. Conduct comprehensive clinical and psychosocial assessments to evaluate patients' readiness for transition between care settings Develop, implement, and regularly update individualized transitional care plans in collaboration with the interprofessional team Coordinate discharge planning, including arranging follow-up appointments, home health services, durable medical equipment, and community resources Provide patient and family education on diagnoses, medications, self-management strategies, and post-discharge care instructions Communicate effectively with physicians, case managers, social workers, and post-acute providers to ensure continuity of care Monitor patient progress, identify barriers to safe discharge, and advocate for needed services and interventions Document all assessments, care plans, education, and coordination activities accurately in the electronic health record Participate in quality improvement initiatives focused on reducing readmissions and improving transitional care outcomes Contribute to interdisciplinary rounds, case conferences, and team meetings to review and optimize patient care plans Maintain compliance with hospital policies, professional nursing standards, and regulatory requirements Clinical nursing assessment and intervention Transitional care and discharge planning Care coordination and case management Patient and family education Knowledge of chronic disease management and readmission reduction strategies Electronic health record (EHR) xevrcyc documentation Interdisciplinary teamwork and collaboration Critical thinking and clinical decision-making Time management and prioritization Knowledge of community and post-acute care resources Medication management and patient teaching Strong written and verbal communication skills Medical Insurance Dental Insurance Vision Insurance Life Insurance 401k Active Registered Nurse (RN) license in the state of practice Basic Life Support (BLS) certification Advanced Cardiovascular Life Support (ACLS) certification Clinical experience in transitional care, step-down, or med-surg settings Case management or care coordination experience preferred Specialty certification in transitional care or case management (e.g., CCCTM, CCM) preferred