**Responsibilities** + Completes and documents a discharge planning assessment on those patients identified by the designated screening process or upon request.Reassess the patient as appropriate and update the plan accordingly. + Facilitates the development of a multidisciplinary discharge plan engaging other relevant health team members the patient and/or patient representative and post acute care providers in accordance with the patients clinical or psychosocial needs choices and available resources. + Oversees and evaluates the implementation of the discharge plan. + Collaborates with the multidisciplinary team to ensure progression of care and appropriate utilization of inpatient resources using established evidence based guidelines/criteria. + Collaborates with the healthcare team and post-acute service providers to ensure timely and smooth transitions to the most appropriate type and setting of post-acute services based upon patients clinical needs. + Identifies risk for readmission and implements interventions to mitigate those risks for at least a 30-day period. + Responsible for delivery of appropriate patient notifications and related documentation + Responsible for patient education and advocacy. **Qualifications** + Graduate of an accredited school of nursing. + Minimum two (2) years of acute hospital clinical experience + RN license in the state(s) covered is required. + BLS required within 3 months of hiring if located within hospital **Overview** CHI Health Immanuel, located in North Omaha just off of I-680 on 72nd Street, offers a full-service hospital, cancer center, rehabilitation center, specialty spine hospital and more. For well over a century, our commitment to serve our community inspires our staff to provide the highest quality of care to all who we have the privilege to serve. **Pay Range** $32.70 - $48.65 /hour We are an equal opportunity/affirmative action employer.