RN Post-Acute Care Coordinator - Transition Liaison

INTEGRIS Health; Oklahoma City (OK); On-site; USD 70,000 - 90,000; Full time

Job summary

INTEGRIS Health is seeking a day shift, full-time RN Post Acute Coordinator for INTEGRIS Health South Medical Center in Oklahoma City. The role focuses on coordinating transitions from inpatient to ambulatory services and ensuring timely referrals for home health, hospice, DME, and therapy.

You will work with case managers and physicians to prevent discharge delays, educate patients about next steps, and document outcomes in the EHR. A strong communicator with coordinating skills is essential.

Qualifications

• RN with 3+ years in care coordination or ambulatory services.
• Familiarity with Medicare/Medicaid eligibility for home health and DME.
• Strong communication and organizational skills.
• Ability to collaborate across clinical and operational teams.
• Proficiency in EHRs and referral management platforms.

Responsibilities

• Act as liaison between inpatient case managers and ambulatory services.
• Identify referral-sensitive patients and initiate service line referrals.
• Coordinate transitions to internal services including home health, hospice, DME, therapy, and follow-up care.
• Schedule follow-up appointments with employed physicians post-discharge.
• Educate patients and families on next steps after discharge.
• Track referral status and ensure service activation prior to discharge.
• Collaborate with case managers and physicians to prevent discharge delays.
• Document interventions and outcomes in the EHR.

Skills

RN

Care coordination

Ambulatory services

Tools

Electronic Health Records

Job description

INTEGRIS Health is seeking a day shift, full-time RN Post Acute Coordinator for INTEGRIS Health South Medical Center in Oklahoma City. The role focuses on coordinating transitions from inpatient to ambulatory services and ensuring timely referrals for home health, hospice, DME, and therapy.

You will work with case managers and physicians to prevent discharge delays, educate patients about next steps, and document outcomes in the EHR. A strong communicator with coordinating skills is essential.