RN, Hospital-to-Home Care Navigator

UW Health; Madison (WI); On-site; USD 75,000 - 95,000; Full time

Job summary

UW Health is seeking a Registered Nurse to lead patient transitions from traditional inpatient care to home-based hospital care (HBHC) at University Hospital and East Madison Hospital. The role involves bedside intake, coordination with physicians, and ensuring smooth handoffs to the HBHC team.

The position emphasizes autonomy and collaboration, with travel between sites as needed and a strong focus on care continuity and patient safety.

Qualifications

• Bachelor's Degree in Nursing (BSN) preferred.
• 2 years relevant acute care or home health nursing experience required.
• Experience in care coordination, triage, or nursing leadership preferred.
• Experience in program development preferred.
• Experience in teaching self-care skills to patients and families preferred.
• Recent, relevant home health experience preferred.
• Experience using EPIC and virtual health platforms preferred.
• Experience with IV therapy and knowledge of venous-access devices and ambulatory pumps preferred.

Responsibilities

• Conduct bedside intake, eligibility screening, and informed consent discussions to transition patients from inpatient care to acute care at home.
• Partner daily with the admitting physician to review patient lists, identify top candidates, and coordinate timely discharges to home-based hospital services.
• Prepare patients for departure by arranging transportation, coordinating equipment and appropriate care supplies, and ensuring a smooth handoff to the HBHC interdisciplinary team.
• Serve as a key connector between hospital and home, collaborating closely with providers, nursing teams, and support services to launch each patient’s HBHC episode successfully.

Skills

Bedside nursing

Care coordination

Triage

EPIC

IV therapy

Education

BSN preferred

Tools

EPIC

Virtual health

Job description

UW Health is seeking a Registered Nurse to lead patient transitions from traditional inpatient care to home-based hospital care (HBHC) at University Hospital and East Madison Hospital. The role involves bedside intake, coordination with physicians, and ensuring smooth handoffs to the HBHC team.

The position emphasizes autonomy and collaboration, with travel between sites as needed and a strong focus on care continuity and patient safety.