RN Care Coordinator: Post-Acute Transitions & Care Planning

SOFHA EMPLOYMENT SERVICES INC; Johnson City (TN); On-site; USD 65,000 - 85,000; Full time

Benefits offered by this job

Company match in Health Savings Plan

Life Insurance

Long Term Disability Insurance

401(k) Plan

Tuition Assistance

Job summary

State of Franklin Healthcare Associates is seeking a registered nurse to lead patient transitions from inpatient to home or post-acute settings. The role focuses on developing personalized care plans and using motivational interviewing to improve outcomes.

You will document progress in the medical record and CareTrac, coordinate resources, and support providers in closing care gaps through outreach. A valid RN license is required.

Qualifications

• RN license in good standing
• Experience in transitions of care preferred
• Strong documentation and communication skills

Responsibilities

• Develop, initiate and monitor a care plan for patients transitioning from inpatient to home or post-acute settings.
• Utilize motivational interviewing to support patient outcomes and engagement.
• Document care plans and progress accurately in the medical record and CareTrac.
• Identify social determinants of health and coordinate community resources and social work support.

Skills

Motivational interviewing

Care coordination

Medical record documentation

CareTrac experience

Education

RN - Registered Nurse

Tools

CareTrac EMR

Job description

State of Franklin Healthcare Associates is seeking a registered nurse to lead patient transitions from inpatient to home or post-acute settings. The role focuses on developing personalized care plans and using motivational interviewing to improve outcomes.

You will document progress in the medical record and CareTrac, coordinate resources, and support providers in closing care gaps through outreach. A valid RN license is required.