RN Health Promotion Nurse

Conduct discharge follow-ups for patients recently released from inpatient or emergency settings to evaluate status, perform medication reconciliations, and coordinate follow-up care. Create and update patient-specific care plans that include goal setting, health risk assessments, and preventive screenings while utilizing motivational interviewing to support self-management. Monitor EHR reports and payer portals for discharge notifications, collaborate with outside facilities for timely records, and assess social determinants of health to connect patients with community resources. Schedule annual exams, arrange transportation, and coordinate prescriptions to ensure continuity of care, while documenting all interactions clearly and contributing to quality improvement activities regarding readmissions and ED utilization.