RN Care Transitions Specialist - Home Health

Avera Health; Sioux Falls (SD); On-site; USD 43,000 - 63,000; Full time

Job summary

Avera Health in Sioux Falls is seeking a Registered Nurse to manage care transitions, including patient assessments, care planning, and home visits. You will work within a multidisciplinary team to ensure effective discharge planning and follow-up.

The role emphasizes coordinating care across facilities, educating patients and families, and ensuring timely access to services. Must live within 1.5 hours of an Avera facility and be able to perform in a fast-paced environment.

Qualifications

• Must be a Registered Nurse with an active license in the state of practice.
• Experience in home health or hospice is preferred.
• Ability to communicate effectively with patients, families, and team members.

Responsibilities

• Perform admission and follow-up calls using the nursing process and document in the EMR.
• Develop patient-centered care plans and coordinate care with home health agencies and community resources.
• Provide education and disease management information to patients and caregivers as directed by the physician.

Skills

Nursing assessment

Care coordination

Triage

Education

Registered Nurse license - active

Job description

Avera Health in Sioux Falls is seeking a Registered Nurse to manage care transitions, including patient assessments, care planning, and home visits. You will work within a multidisciplinary team to ensure effective discharge planning and follow-up.

The role emphasizes coordinating care across facilities, educating patients and families, and ensuring timely access to services. Must live within 1.5 hours of an Avera facility and be able to perform in a fast-paced environment.