RN Care Coordinator: Discharge & Care Transitions

Virginia Commonwealth University Health Systems; Richmond (VA); On-site; USD 73,000 - 121,000; Full time

Job summary

Tappahannock Hospital is seeking an experienced RN to lead patient transitions from hospital to home or to next care settings. You will work with the care team to assess needs, coordinate services, and ensure timely, safe discharges.

The role emphasizes collaboration with physicians, social workers, and community agencies, while maintaining compliance with regulatory guidelines and protecting patient safety.

Qualifications

• Licensed Registered Nurse in Virginia or eligible.
• Current VA RN licensure; 15 Continuing Education Units per year.
• Minimum 3 years of nursing experience in an acute care setting.
• BSN from an accredited school or a Bachelor's in a biological/health/science field.
• Master's Degree in Nursing or healthcare-related field preferred.

Responsibilities

• Collaborate with attending and consulting physicians to facilitate transitions through hospitalization.
• Coordinate with multidisciplinary team to meet patient needs and ensure coordinated care across continuum.
• Consult social workers to resolve psychosocial issues and develop complex discharge plans.
• Liaise between hospital and community agencies for referrals and information exchange.
• Ensure compliance with CMS/QIO guidelines and risk management requirements.

Skills

Nursing

Care Coordination

Discharge Planning

Interdisciplinary Collaboration

Education

BSN

Biological/Health Sci bachelor's

MSN (preferred)

Job description

Tappahannock Hospital is seeking an experienced RN to lead patient transitions from hospital to home or to next care settings. You will work with the care team to assess needs, coordinate services, and ensure timely, safe discharges.

The role emphasizes collaboration with physicians, social workers, and community agencies, while maintaining compliance with regulatory guidelines and protecting patient safety.