Onsite Care Coordination Nurse

Provide comprehensive, face-to-face assessments of newly admitted members in acute care settings and lead care coordination to ensure safe, timely transitions from hospital to home. Identify gaps in care and barriers to discharge, develop and implement strategies with providers and care teams, educate members and families on discharge planning and preventive measures, and maintain accurate documentation while upholding infection control and privacy standards. Collaborate with facility staff, case managers, and health plans to optimize readmission reduction and overall member wellness. This role combines in-person engagement at assigned facilities with remote coordination tasks in a hybrid model, based in Fort Pierce, FL with occasional travel.