RN Care Coordination Lead — Discharge & Transitions

Riverside Health; Newport News (VA); Hybrid; USD 53,000 - 73,000; Full time

Job summary

Riverside Health in Newport News, Virginia, seeks a skilled RN for discharge planning and case management. You will lead the discharge process, assess clinical and psychosocial needs, and coordinate smooth transitions to home or other care settings to optimize outcomes.

The role requires 3–4 years of nursing experience, an active Virginia RN license, and collaboration with an interdisciplinary team to ensure regulatory compliance and patient-centered care.

Qualifications

• RN license required in Virginia (VDHP)
• 3–4 years clinical experience required
• 1 year case management preferred

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 safe transitions to home, SNF, rehab, or behavioral health.

Skills

Discharge planning

Care coordination

Interdisciplinary collaboration

Patient education

Education

Diploma in Nursing

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Job description

Riverside Health in Newport News, Virginia, seeks a skilled RN for discharge planning and case management. You will lead the discharge process, assess clinical and psychosocial needs, and coordinate smooth transitions to home or other care settings to optimize outcomes.

The role requires 3–4 years of nursing experience, an active Virginia RN license, and collaboration with an interdisciplinary team to ensure regulatory compliance and patient-centered care.