RN Care Coordinator - Transition of Care (Outpatient)

Hunterdon Health; Flemington (NJ); On-site; USD 70,000 - 75,000; Full time

Job summary

Hunterdon Healthcare is seeking an RN Care Coordinator to join the outpatient team. You will work with a multidisciplinary group to coordinate care for high-risk patients, promoting seamless transitions and quality outcomes as patients move through the healthcare continuum.

The role requires strong communication, hospital or home health experience, NJ RN licensure, and may involve CMS guidelines for post-discharge visits.

Qualifications

• Requires BSN or RN with home health/acute care experience; CCM a plus.
• Minimum of 3 years direct inpatient/outpatient care.
• 5 years acute care and care coordination preferred.
• NJ RN licensure required.

Responsibilities

• Provide outreach and coordinate care across primary, specialty, and home health services.
• Develop relationships with hospitals, case managers, discharge planners, and ED contacts.
• Create systems to ensure post-discharge and ongoing medical needs are met.
• Monitor care coordination with home care agencies and specialists.
• Ensure Transition Care Management visits are completed within CMS guidelines.
• Educate patients and caregivers about diagnoses, medications, and discharge instructions.
• Collaborate with the team and participate in meetings or committees as requested.

Skills

Communication skills

Interdisciplinary collaboration

Care coordination

Education

BSN or RN

CCM certification

Tools

EMR software

Job description

Hunterdon Healthcare is seeking an RN Care Coordinator to join the outpatient team. You will work with a multidisciplinary group to coordinate care for high-risk patients, promoting seamless transitions and quality outcomes as patients move through the healthcare continuum.

The role requires strong communication, hospital or home health experience, NJ RN licensure, and may involve CMS guidelines for post-discharge visits.