RN Care Transitions Lead: Post-Discharge Coordination

Community Health Care, Inc.; Canal Fulton (OH); On-site; USD 55,000 - 75,000; Full time

Benefits offered by this job

Medical insurance

401(k) and Roth 401(k)

401(k) employer match

Dental insurance

Term Life Insurance

Vision insurance

Wellness benefits

Paid time off

Personal days

Short term disability

Long Term disability

Paid holidays

Employee assistance program

Travel assistance program

Job summary

Community Health Care Canal Fulton seeks an in-office Transition of Care Coordinator (RN or LPN) to coordinate post-discharge care and improve patient outcomes. Join a team that values patient-centered care and collaboration across hospital and home-based services.

You will conduct post-discharge interviews, reconcile medications, arrange home care or medical equipment, and work closely with hospital nurses to ensure smooth transitions and advocacy for patients.

Qualifications

• RN or LPN license required.
• Experience with hospital systems and skilled nursing facilities.
• Ability to work across multiple Electronic Health Record platforms.
• Strong clinical decision making and communication skills.

Responsibilities

• Conduct post-discharge patient interview via phone
• Assess and identify patient needs post-discharge
• Reconcile medication list post-discharge
• Coordinate patient care such as home care or medical equipment
• Work collaboratively with hospital-based transition of care nurses and staff
• Act as patient advocate
• Organizational tasks
• Identify patients who have had a transition of care
• Contact patients within 48 hours of inpatient discharge or within 7 days of Emergency Room visit
• Follow patient course of stay while in Skilled Nursing Facility until discharge to home
• Retrieve patient records from multiple hospital systems, review records, update patient chart
• Concurrent documentation in telephone encounters in patient chart
• Refer patients to long-term care management when appropriate

Skills

Clinical decision making

Critical thinking

Verbal communication

Written communication

Teaching others

Teamwork

Education

RN or LPN

Job description

Community Health Care Canal Fulton seeks an in-office Transition of Care Coordinator (RN or LPN) to coordinate post-discharge care and improve patient outcomes. Join a team that values patient-centered care and collaboration across hospital and home-based services.

You will conduct post-discharge interviews, reconcile medications, arrange home care or medical equipment, and work closely with hospital nurses to ensure smooth transitions and advocacy for patients.