Registered Nurse - Transition Coor- HF at Home - ...

GENERAL SUMMARY: Works to ensure accurate and appropriate gathering of demographic and clinical patient information prior to discharge from the hospital and start of care. Assesses patient for appropriateness of Henry Ford at Home services, identifying support required regarding the patient's needs. Is responsible for educating, developing and strengthening relationships with referral sources, senior leaders, and Henry Ford at Home providers. Coordinates and assists hospital/facility case managers in ensuring a smooth transition for patients from the inpatient setting and/or physician offices. Provides home infusion visits in patient homes and manage patient caseloads when applicable. The Hospital at Home requisition needs to reflect that this is an inpatient admission eligibility screening and collaboration role. + Assessing patients for eligibility based on inpatient admission criteria + Completing all screening using clinical judgment + Presenting cases to the Medical Director for approval + If approved, approaching the ER physician for final acceptance + Coordinating transportation, inpatient medications, infusions, oxygen, and DME to transition the patient home as quickly as possible so inpatient u2011 level care can begin in the home This role does not include home visits. The Transition Coordinator will focus on program education only and will primarily be stationed in the ER and observation areas. Other TCs already support at u2011 home services. EDUCATION/EXPERIENCE REQUIRED: + Requires graduation from an accredited Registered Nurse program. + Current licensure by the State of Michigan as a registered nurse required. + Minimum of one-year clinical nursing experience required;IV administration experience preferred. + Requires a professional and clinical level of analytical skills in order to solve problems, analyze, and develop procedures and plans. + Requires the ability to communicate effectively, generate, and maintain positive relationships with the medical team. + Patient education experience preferred. + Knowledge of regulatory/reimbursement requirements for Henry Ford at Home products and services and ability to identify various payor issues and appropriate channels for coverage approval preferred. + Knowledge of computer use is required to electronically document patient care. + Project a professional and courteous image to internal and external customers. + Must possess a valid driver's license, a satisfactory driving record and reliable transportation. + Must be able to lift, carry, transport and move clients as needed. CERTIFICATIONS/LICENSURES REQUIRED: Registered Nurse in the State of Michigan. Additional Information + Organization: Community Care Services + Department: Hospital at Home - Team A + Shift: Day Job + Union Code: Not Applicable Additional Details This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above. Overview Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services u2013 from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Fordu2019s care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nationu2019s most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus. Learn more at /careers . Benefits The health and overall well-being of our team members is our priority. Thatu2019s why we offer support in the various components of our teamu2019s well-being: physical, emotional, social, financial and spiritual. Our Total Rewards program includes competitive health plan options, with three consumer-driven health plans (CDHPs), a PPO plan and an HMO plan. Our team members enjoy a number of additional benefits, ranging from dental and eye care coverage to tuition assistance, family forming benefits, discounts to dozens of businesses and more. Employees classified as contingent status are not eligible for benefits. Equal Employment Opportunity/Affirmative Action Employer Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health is committed to the hiring, advancement and fair treatment of all individuals without regard to race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height, weight, marital status, family status, gender identity, sexual orientation, and genetic information, or any other protected status in accordance with applicable federal and state laws.

Created: 2026-02-13