PRIMARY RESPONSIBILITIES - Ensures compliance with Condition of Participation (CoP) discharge planning. - Identifies and escalates gaps/barriers related to inpatient and observation length of stay. - Assesses patients at high risk for readmission. Identifies root cause for readmission. Develops plan and collaborates with multidisciplinary team regarding discharge planning to next level of care. - Participates with other members of team regarding opportunities for improvement in standard work. - May also be responsible for: utilization management process, ED case management process, admission process, and act as a case manager liaison with post acute providers (skilled nursing facilities, rehab, home health, etc.). - Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient's age-specific needs and clinical needs as described in the department's Scope of Service. - As an SSM Health nurse, I will demonstrate the professional nursing standards defined in the professional practice model. Uses the ANA Code of Ethics for Nurses to guide his/her response to the current and evolving health and nursing needs of our patients and our patient populations. - Performs other duties as assigned. EDUCATION - Graduate of accredited school of nursing EXPERIENCE - Three years' acute care experience SSM Health is committed to equal employment opportunity based on race, color, religion, national origin, gender, sexual orientation, gender identity, pregnancy, age, physical or mental disability, veteran status, and all other statuses protected by law.