RN Post-Acute Coordinator - South

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

Job Description

Join our team as a day shift, full time, RN Post Acute Coordinator, at INTEGRIS Health South Medical Center, in Oklahoma City.

Job Description

Join our team as a day shift, full time, RN Post Acute Coordinator, at INTEGRIS Health South Medical Center, in Oklahoma City.

Get to Know Your Team

• INTEGRIS Health, Oklahoma’s largest not-for-profit health system, is seeking a dedicated caregiver to join us in our mission to partner with people to live healthier lives.
• Benefits of being an INTEGRIS Health caregiver include front-loaded PTO, medical benefits through the extensive INTEGRIS Health network, financial assistance for continued education, 24/7 mental health support and more.
• Take the first step toward growing your career by joining us.

Responsibilities

The clinical post-acute coordinator is a liaison between inpatient case managers and the health system’s suite of ambulatory services. The post-acute coordinator is responsible for identifying patients with referral-sensitive needs, initiating service line referrals, and coordinating transitions to internal services including home health, hospice, DME, outpatient therapy, sleep medicine, pharmacy, and follow-up care with the employed medical group.

The Post-Acute Coordinator responsibilities include, but are not limited to, the following:

• Participate in daily interdisciplinary rounds to identify referral-sensitive patients
• Screen for eligibility across all internal ambulatory services
• Coordinate referrals with home health, hospice, DME, therapy, wound care, and pharmacy intake teams
• Directly schedule follow-up primary and specialty care appointments with employed physicians
• Educate patients and families on next steps and what to expect post-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

The clinical post-acute Coordinator will report to the Director of Ambulatory Operations and be responsible for referral conversions, case manager satisfaction, and troubleshooting barriers to discharge.

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

About Us

INTEGRIS Health mission: Partnering with people to live healthier lives.

To our patients, that means we will partner to provide unprecedented access to quality and compassionate health care. To you, it means some of the state’s best career and development opportunities. With INTEGRIS Health, you will have a genuine chance to make a difference in your life and your career.

INTEGRIS Health is the state's largest Oklahoma-owned health system with hospitals, rehabilitation centers, physician clinics, mental health facilities and home health agencies throughout much of the state.