RN | Transitional Care Manager — Readmission Prevention

Southwoods Health; Boardman Township (OH); On-site; USD 65,000 - 90,000; Full time

Job summary

Southwoods Health in Boardman, OH is seeking a full-time Registered Nurse (RN) for the Transitional Care Management Clinic. You will support patients recently discharged from acute care, gathering clinical data and helping prevent readmissions.

Responsibilities include post-acute assessments by phone, coordinating care, scheduling follow-up visits, and documenting calls in the EMR while ensuring patient privacy and regulatory compliance.

Qualifications

• BSN preferred.
• Strong critical thinking and time management required.
• Clear, professional, empathetic phone communication.

Responsibilities

• Conduct post-acute phone assessments to identify barriers to recovery.
• Review discharge instructions, medications and referrals for each patient.
• Schedule and facilitate face-to-face follow-up visits.
• Log patient calls accurately in the EMR system.
• Maintain patient privacy and follow OSHA/ODH regulatory standards.

Skills

Critical thinking

Time management

Communication

Education

BSN preferred

Job description

Southwoods Health in Boardman, OH is seeking a full-time Registered Nurse (RN) for the Transitional Care Management Clinic. You will support patients recently discharged from acute care, gathering clinical data and helping prevent readmissions.

Responsibilities include post-acute assessments by phone, coordinating care, scheduling follow-up visits, and documenting calls in the EMR while ensuring patient privacy and regulatory compliance.