Care Transitions Registered Nurse

Affinity Home Health Care Inc; Oklahoma City (OK); On-site; USD 65,000 - 90,000; Full time

Job summary

Affinity Home Health Care Inc. Hospital Community RN Liaison position bridging hospital, home, and community care. You will coordinate safe transitions of care, perform nursing assessments, and educate patients and families on treatment plans and follow-up steps.

You will collaborate with physicians, social workers, and community providers to connect patients with essential community resources and services, ensuring continuity of care after discharge.

Qualifications

• Registered Nurse with strong clinical assessment and care coordination skills.
• Excellent communication and patient/family education abilities.
• Ability to collaborate effectively within a multidisciplinary team.
• Commitment to safe discharge planning and continuity of care.

Responsibilities

• Coordinate and support transitions of care to reduce readmissions
• Perform nursing assessments and monitor patient needs during handoffs
• Provide patient and family education on care plans, medications, and next steps
• Collaborate with physicians, social workers, and community providers
• Connect patients with essential community resources and services

Skills

Registered Nurse

Nursing assessment

Care coordination

Communication

Patient education

Discharge planning

Job description

Hospital Community RN Liaison

Serve as a field-based RN liaison bridging care across hospital, home, and community. Coordinate safe transitions of care, conduct comprehensive nursing assessments, and educate patients and families on treatment plans, medications, and follow-up requirements.

Key Duties

• Coordinate and support transitions of care to reduce readmissions
• Perform nursing assessments and monitor patient needs during handoffs
• Provide patient and family education on care plans, medications, and next steps
• Collaborate with physicians, social workers, and community providers
• Connect patients with essential community resources and services

Qualifications & Skills

• Registered Nurse with strong clinical assessment and care coordination skills
• Excellent communication and patient/family education abilities
• Ability to collaborate effectively within a multidisciplinary team
• Commitment to safe discharge planning and continuity of care