RN Care Coordination Lead: Discharge & Transitions

Riverside Regional Medical Center; Newport News (VA); On-site; USD 80,000 - 110,000; Full time

Job summary

Riverside Health System in Newport News, VA is seeking a Registered Nurse to lead discharge planning across the care continuum. You will assess patient needs, develop cost-effective discharge plans, and coordinate transitions to appropriate care settings.

The role emphasizes collaboration with the care team, patients and families, with attention to CMS regulations and quality outcomes.

Qualifications

• 3-4 years clinical experience required.
• 1 year case management experience preferred.
• RN licensure in Virginia or eligible upon hire.
• ACM certification preferred upon hire.

Responsibilities

• Lead discharge planning from admission through post-discharge follow-up.
• Conduct comprehensive assessments of patients' clinical and psychosocial needs.
• Develop, implement and update individualized discharge plans.
• Coordinate transitions to home, SNF, acute rehab, or behavioral health.
• Collaborate with the interdisciplinary team, patient and family for safe planning.
• Attend rounds, case conferences and family meetings; communicate updates clearly.
• Ensure CMS and state discharge planning compliance and accurate documentation.
• Educate patients and families on treatment plans and options.

Skills

Clinical experience

Case management

Discharge planning

Interdisciplinary collaboration

Education

Nursing diploma or equivalent

Associate degree in nursing

Bachelor's degree in nursing

Job description

Riverside Health System in Newport News, VA is seeking a Registered Nurse to lead discharge planning across the care continuum. You will assess patient needs, develop cost-effective discharge plans, and coordinate transitions to appropriate care settings.

The role emphasizes collaboration with the care team, patients and families, with attention to CMS regulations and quality outcomes.