RN Care Coordinator: Hospital-to-Home Transitions

Sioux Center Health; Sioux Falls (SD); On-site; USD 45,000 - 68,000; Full time

Job summary

Avera McKennan Hospital in Sioux Falls, SD is seeking a PRN RN to coordinate patient care across hospital and home settings. The role emphasizes ensuring safe transitions and post-acute planning for home health or hospice services.

You will obtain orders, develop and communicate care plans, educate patients and families, and collaborate with physicians, home health agencies, and other teams to support high-quality care.

Qualifications

• Active RN license in the state of practice; license must be current upon hire.
• Preferred 1–3 years’ home health/hospice experience.

Responsibilities

• Serves as home care expert and resource to referral sources and agency staff regarding patient care in the home/hospice setting.
• Provides clinical assessment and assists referral sources with identification of appropriate services in the post-acute home care setting including education regarding admission criteria.
• Obtains physician orders, including face-to-face, for home care/hospice services prior to each patient’s admission to home care.
• Coordinates the home care/hospice plan as ordered by the physician.
• Clinical excellence and ability to proactively determine actual and potential complications in the home setting of care delivery for success of the patient.
• Documents each patient’s home care plan and coordination activities according to standards established by Avera.
• Maintains knowledge of Federal and State regulations as well as Agency policies and procedures.

Education

Registered Nurse (RN) - Board of Nursing

Job description

Avera McKennan Hospital in Sioux Falls, SD is seeking a PRN RN to coordinate patient care across hospital and home settings. The role emphasizes ensuring safe transitions and post-acute planning for home health or hospice services.

You will obtain orders, develop and communicate care plans, educate patients and families, and collaborate with physicians, home health agencies, and other teams to support high-quality care.