GENERAL SUMMARY: The Care Transitions RN conducts day-to-day activities for the clinical, psychosocial and utilization coordination of the patient#s hospital experience.# Proactively consults with the interdisciplinary team which includes but is not limited to hospital patient care staff, physicians, patient support and family and community resources to assure a smooth transition for the patient through appropriate levels of care in order to facilitate quality outcomes. PRINCIPAL JOB FUNCTIONS: *Commits to the mission, vision, beliefs and consistently demonstrates our core values. *Utilizes clinical skills to create and update personalized transitional care plans for patients. *Performs transition planning activities at onset and throughout the patient#s hospitalization.