Care Coordination Nurse

Jobtailor; Madison (WI); Hybrid; USD 85,000 - 110,000; Full time

Job summary

Jobtailor is seeking an experienced RN to conduct comprehensive assessments for admitted patients at UW Health University Hospital and coordinate discharge planning and care transitions. The role involves evaluating physical and psychosocial needs and referring patients to Humana programs when appropriate.

The position requires strong documentation, collaboration with care teams, and education for patients and families, including post-discharge planning and follow-up with primary care providers.

Qualifications

• Active RN license in Wisconsin, unrestricted.
• Minimum 3 years acute care nursing experience.
• Experience with discharge planning or care coordination in hospital or health plan setting.
• Private workspace for remote documentation with adequate internet speed.
• Bilingual English/Spanish preferred.

Responsibilities

• Conduct comprehensive face-to-face assessments of newly admitted members at assigned acute care facilities.
• Evaluate members’ physical, psychosocial, and health needs and refer them to Humana programs as appropriate.
• Support and educate members and families on discharge planning from admission through post-discharge.
• Facilitate follow-up visits with primary care providers.
• Identify gaps in care, safety concerns, and barriers to discharge.
• Develop and implement strategies to address care and discharge barriers.
• Collaborate with attending providers, facility case managers, and other healthcare professionals.
• Provide education on diagnoses, medications, and preventive measures.
• Complete required documentation accurately and promptly.
• Maintain infection control, safety, and patient privacy standards.
• Coordinate care onsite and complete documentation remotely as permitted.

Skills

Acute Care Nursing

Care Coordination

Discharge Planning

Patient Assessment

Documentation

Infection Control

Health Education

HEDIS Knowledge

Stars Measures Knowledge

Care Management

Education

Bachelor's degree in Nursing (BSN) preferred

Current, unrestricted RN license in Wisconsin

Tools

Microsoft Office

Electronic Medical Records

Remote Documentation Tools

Job description

• Conduct comprehensive face-to-face assessments of newly admitted members at assigned acute care facilities
• Evaluate members’ physical, psychosocial, and health needs and refer them to Humana programs as appropriate
• Support and educate members and families on discharge planning from admission through post-discharge
• Facilitate follow-up visits with primary care providers
• Identify gaps in care, safety concerns, and barriers to discharge
• Develop and implement strategies to address care and discharge barriers
• Collaborate with attending providers, facility case managers, and other healthcare professionals
• Provide education on diagnoses, medications, and preventive measures
• Complete required documentation accurately and promptly
• Maintain infection control, safety, and patient privacy standards
• Coordinate care onsite and complete documentation remotely as permitted

Requirements

• Current, unrestricted Registered Nurse (RN) license in the state of Wisconsin
• Must be located within a 30–60 minute driving distance to UW Health University Hospital, 600 Highland Ave, from home base
• Minimum of 3 years recent acute care nursing experience
• Experience with discharge planning or care coordination in a hospital or health plan setting
• Experience with Microsoft Office applications (Word, Outlook, Excel) and electronic medical records
• Valid driver’s license, dependable automobile, and proof of personal vehicle liability insurance
• Participation in Tuberculosis (TB) screening and ACHA Level II background clearance, including fingerprinting
• Other credentialing and screening as required by assigned facility
• Private workspace for remote documentation when not in the field
• Minimum internet speed of 25 Mbps download and 10 Mbps upload
• Dedicated workspace without ongoing interruptions to protect PHI/HIPAA information
• Bachelor’s degree in Nursing (BSN) preferred
• Experience in care management, health promotion, or coaching preferred
• Previous Utilization Management experience preferred
• Previous health plan experience preferred
• Bilingual English/Spanish preferred
• Certification in Care Management or related specialty preferred
• Knowledge of HEDIS and Stars measures preferred

Core Competencies

Demonstrates expertise in conducting comprehensive assessments, care coordination, and discharge planning while ensuring compliance with safety and privacy standards. Proficient in collaborating with healthcare professionals and educating members on health needs and preventive measures.

Highest-signal resume keywords

• Registered Nurse (RN) License
• Acute Care Nursing Experience
• Discharge Planning Experience
• Care Coordination Experience
• Bilingual English/Spanish

ATS Optimization Keywords

Hard Skills

• Acute Care Nursing
• Care Coordination
• Discharge Planning
• Patient Assessment
• Documentation
• Infection Control
• Health Education
• HEDIS Knowledge
• Stars Measures Knowledge
• Care Management

Soft Skills

• Collaboration
• Communication
• Problem-Solving
• Patient Advocacy
• Education

Certifications & Qualifications

• Care Management Certification
• ACHA Level II Background Clearance

Industry Keywords

• Acute Care Facilities
• Health Plan
• Patient Privacy Standards
• Tuberculosis Screening
• Utilization Management

Tools & Technologies

• Microsoft Office
• Electronic Medical Records
• Remote Documentation Tools