Care Transitions Registered Nurse (RN)

LAKE REGION HEALTHCARE CORPORATION; Fergus Falls (MN); On-site; USD 59,000 - 75,000; Full time

Benefits offered by this job

Sign-on bonus

Comprehensive benefits

Job summary

Lake Region Healthcare is seeking a Care Transitions Registered Nurse (RN) to coordinate patient care from hospital to home or another setting, aiming to reduce readmissions and ensure safe transitions. This role collaborates with patients, families, and a broad care team, performing assessments, discharge planning, and education on disease management and follow-up care.

Hours are 80 biweekly, day shifts, with compensation in the low-mid $40s to mid $50s per hour, plus a sign-on bonus and

Qualifications

• Active, unrestricted RN license in the applicable state.
• Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN).
• Care Transitions Certification (CTC) or case management certification preferred.
• Minimum of 2 years of clinical experience in acute care, discharge planning, home health, or case management.

Responsibilities

• Assess high-risk patients to identify medical, social, and environmental risk factors.
• Develop discharge plans with patients, families, and physicians.
• Coordinate services including home health, remote patient monitoring, and pharmacy needs.
• Educate patients and families on disease management and follow-up care; review discharge instructions and medication schedules.
• Serve as liaison between inpatient providers, primary care providers, specialists, and external health agencies.

Skills

Communication

Interpersonal skills

Critical thinking

Problem solving

EHR proficiency

Education

ADN/BSN

CTC certification

Tools

EHR (Electronic Health Records)

Job description

The Care Transitions Registered Nurse (RN) coordinates patient care from the hospital/emergency department to home or another facility to lower readmission rates and ensure a safe transition and follow up. This position collaborates with patients, families, providers, and community resources to support safe transitions of care, improve patient outcomes, and reduce avoidable hospital admissions and readmissions.Duties include but are not limited to:Patient Assessment & PlanningConduct assessments of high-risk patients to identify medical, social, and environmental risk factors.Collaboration to develop a comprehensive discharge plan in partnership with patients, families, and physicians.Develop individualized care plans focusing on medication management and follow-up care.Care Coordination & CommunicationServe as a liaison between inpatient providers, primary care providers, specialists, and external health agencies.Coordinate services including home health, durable medical equipment, remote patient monitoring, and pharmacy needs.Collaboration with internal and external care teamsOther care coordinator duties as assignedPatient & Family EducationProvide education on disease management, warning signs, and escalation protocols.Review discharge instructions and medication schedules during post-discharge and emergency department follow-up calls.Collaboration with patient and/or families in coordination of careHours/Shifts80 hours biweekly, day shifts, Monday to Friday.CompensationHourly wage range: $42.63 - $54.57. Please note that final compensation will be determined based on experience, qualifications and internal equity considerations. Sign-on bonus available with pro-rated options for part-time hires.Benefit OfferingsLake Region Healthcare is pleased to offer a comprehensive benefit program designed to meet your unique needs. This includes medical and dental coverage; HSA, FSA and 401k plans; EAP, life and disability coverage; voluntary accident, critical illness and hospital indemnity coverage; pet insurance, ID theft protection and legal services. For new employees, the effective date of coverage for most plans is the first of the month, following a 30-day waiting period.EEOCLake Region Healthcare provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.Requirements are representative of minimum levels of knowledge, skill, and/or ability:Education & LicensureActive, unrestricted RN license in the applicable state.Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) from an accredited program.Care Transitions Certification (CTC) or case management certification preferred.ExperienceMinimum of 2 years of clinical experience in acute care, discharge planning, home health, or case management.Core CompetenciesExceptional communication and interpersonal skills.Strong critical thinking and problem-solving abilities.Proficiency in electronic health record (EHR) documentation.