Transition of Care Coordinator (RN)
On-site · Norton, Ohio, United States
Job Summary
In-office Transition of Care Coordinator (RN) coordinates post-discharge patient transitions from inpatient settings to improve patient care and outcomes. Responsibilities include conducting post-discharge patient interviews via phone, reconciling medications, coordinating care such as home care or medical equipment, collaborating with hospital-based transition of care nurses and staff, advocating for patients, identifying patients after discharge or ER visits, following patients through Skilled Nursing Facility stays to discharge, retrieving and updating patient records from multiple hospital systems, documenting in the patient chart, and referring patients to long-term care management when appropriate.
Required Qualifications
- Active RN or LPN license
- Comprehensive knowledge of area hospital systems and skilled nursing facilities
- Medication reconciliation experience
- Ability to work in multiple Electronic Health Record platforms
- Clinical decision making and critical thinking
- Strong verbal and written communication skills
- Ability to teach patients, peers, and staff
- Self-motivated and able to work in an office setting
- Teamwork within individual offices and care management teams
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