Onsite Care Coordination RN: Discharge & Transitions

Humana, Inc.; Richmond (VA); Hybrid; USD 71,000 - 98,000; Full time

Job summary

Humana, Inc. is seeking an Onsite Care Coordination Nurse to perform face-to-face assessments for new admissions and lead discharge planning, while coordinating with care teams to ensure safe transitions from hospital to home.

The role blends onsite facility work with remote documentation in a hybrid model. The ideal candidate has an unrestricted Virginia RN license, at least 3 years of acute care experience, and proficiency with Microsoft Office and EMR systems.

Qualifications

• Current, unrestricted RN license in Virginia.
• Within a 30–60 minute drive to VCU Medical Center.
• Minimum of 3 years recent acute care nursing experience.
• Experience with discharge planning or care coordination in hospital or health plan settings.
• Experience in Microsoft Office applications (Word, Outlook, Excel) and electronic medical records.
• Valid driver’s license, dependable automobile, and proof of personal vehicle liability insurance.

Responsibilities

• Conduct comprehensive, face to face assessments of newly admitted members at assigned acute care facilities to evaluate physical, psychosocial, and health needs; refer to Humana programs as appropriate.
• Support and educate members and families on discharge planning from admission through post-discharge, including facilitating follow-up visits with primary care providers.
• Identify gaps in care, safety concerns, and barriers to discharge; develop and implement strategies to address these issues.
• Collaborate with attending providers, facility case managers, and other healthcare professionals to ensure timely, coordinated care and effective discharge planning.
• Provide education on diagnoses, medications, and preventive measures to promote ongoing wellness and reduce risk of readmission.
• Complete all required documentation accurately and promptly.
• Maintain adherence to infection control, safety, and patient privacy standards at all times.

Skills

RN license VA

Acute care nursing

Discharge planning

Care coordination

Microsoft Office & EMR

Driver's license & insurance

Education

BSN (preferred)

Job description

Humana, Inc. is seeking an Onsite Care Coordination Nurse to perform face-to-face assessments for new admissions and lead discharge planning, while coordinating with care teams to ensure safe transitions from hospital to home.

The role blends onsite facility work with remote documentation in a hybrid model. The ideal candidate has an unrestricted Virginia RN license, at least 3 years of acute care experience, and proficiency with Microsoft Office and EMR systems.