Care Transitions Nurse - Home Health

Avera-Healt; Sioux Falls (SD); Remote; USD 43,000 - 64,000; Full time

Benefits offered by this job

PTO from day 1

5% retirement match for eligible staff

Career development and mentorship

Job summary

Avera at Home in Sioux Falls is seeking a Registered Nurse to manage the care of patients in the Care Transitions program. You will perform assessments, develop patient-centered plans, and coordinate follow-up visits and referrals to ensure effective discharge and ongoing care.

The role requires promoting education, coordinating with community resources, and maintaining thorough documentation in the EMR. Flexible schedules and team collaboration support optimal patient outcomes.

Qualifications

• Must be a Registered Nurse with an active license in state of practice.
• Experience in care transitions, home health, or hospice is preferred.
• Ability to assess, plan, and coordinate patient care including follow-up.

Responsibilities

• Manage care for patients in the Care Transitions program.
• Perform patient assessments and develop individualized care plans.
• Provide education and referrals to resources and services.
• Conduct follow-up calls and home visits as part of discharge planning.
• Coordinate with home care agencies and other services as identified.

Skills

Care coordination

Assessment

Patient education

Care planning

Education

RN license

Tools

EMR system

Job description

Avera at Home in Sioux Falls is seeking a Registered Nurse to manage the care of patients in the Care Transitions program. You will perform assessments, develop patient-centered plans, and coordinate follow-up visits and referrals to ensure effective discharge and ongoing care.

The role requires promoting education, coordinating with community resources, and maintaining thorough documentation in the EMR. Flexible schedules and team collaboration support optimal patient outcomes.