Care Coordination Nurse

Jobtailor; South Bend (IN); Hybrid; USD 75,000 - 105,000; Full time

Job summary

Jobtailor is seeking an experienced RN for discharge planning and care coordination within acute care facilities in Indiana. The role emphasizes comprehensive patient assessments, education on diagnoses and medications, and close collaboration with providers to ensure seamless discharge planning.

Qualified candidates will have an active Indiana RN license, 3+ years of acute care experience, and familiarity with EMR systems.

Qualifications

• Current, unrestricted Registered Nurse (RN) license in Indiana.
• Live within a 30–60 minute driving distance of Memorial Hospital.
• 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 and electronic medical records.
• Valid driver’s license and proof of vehicle insurance.

Responsibilities

• Conduct comprehensive face-to-face assessments of newly admitted members at assigned acute care facilities.
• Evaluate physical, psychosocial, and health needs and refer members 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 and facility case managers.
• Ensure timely, coordinated care and effective discharge planning.
• Educate members on diagnoses, medications, and preventive measures.
• Promote ongoing wellness and reduce readmission risk.
• Complete required documentation accurately and promptly.
• Maintain infection control, safety, and patient privacy standards.

Skills

Acute Care Nursing

Discharge Planning

Care Coordination

Collaboration

Communication

Problem-Solving

Empathy

Health Education

Documentation Accuracy

Infection Control

Patient Privacy Standards

HEDIS Knowledge

Stars Measures Knowledge

Education

Bachelor’s degree in Nursing (BSN)

RN License (Indiana)

Tools

Microsoft Office

Electronic Medical Records

Job description

• Conduct comprehensive face-to-face assessments of newly admitted members at assigned acute care facilities


• Evaluate physical, psychosocial, and health needs and refer members 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


• Ensure timely, coordinated care and effective discharge planning


• Educate members on diagnoses, medications, and preventive measures


• Promote ongoing wellness and reduce readmission risk


• Complete required documentation accurately and promptly


• Maintain infection control, safety, and patient privacy standards


• Work at assigned onsite facilities with limited remote hours for coordination and documentation

Requirements

• Current, unrestricted Registered Nurse (RN) license in the state of Indiana


• Must live within a 30–60 minute driving distance of Memorial Hospital - 615 N Michigan Street 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


• Must have a private workspace for remote documentation


• Dedicated workspace without ongoing interruptions to protect member PHI / HIPAA information


• Home internet with minimum download speed of 25 Mbps and upload speed of 10 Mbps


• Preferred: 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

Core Competencies

Demonstrates expertise in acute care nursing, discharge planning, and care coordination, ensuring effective communication and collaboration with healthcare professionals. Proficient in educating members on health needs and maintaining compliance with safety and privacy standards.

Highest-signal resume keywords

• Registered Nurse (RN) License


• Acute Care Nursing Experience


• Discharge Planning Experience


• Care Coordination


• Bilingual English/Spanish

Hard Skills

• Acute Care Nursing


• Discharge Planning


• Care Coordination


• Health Education


• Documentation Accuracy


• Infection Control


• Patient Privacy Standards


• HEDIS Knowledge


• Stars Measures Knowledge

Soft Skills

• Collaboration


• Communication


• Problem-Solving


• Empathy

Certifications & Qualifications

• Certification in Care Management

Industry Keywords

• Health Promotion


• Utilization Management


• Acute Care Facilities


• Patient Safety


• Care Gaps Identification

Tools & Technologies

• Microsoft Office


• Electronic Medical Records