✨ About The Role
- The role involves following members throughout a 30-day program starting at hospital admission and continuing through transitions to other settings
- Responsibilities include collaborating with various healthcare professionals to ensure safe and appropriate transitions for members
- Conducting face-to-face visits in hospitals and home visits for high-risk members post-discharge
- Coordinating care and reassessing member's needs using the Coleman Care Transitions Model
- Educating and supporting members on medication management, follow-up care, nutrition, and other key areas of focus
⚡ Requirements
- Ideal candidate will have 3-4 years of experience in hospital discharge planning or home health
- Must possess an active, unrestricted State Registered Nursing (RN) license in good standing
- Strong time management skills and ability to work in a fast-paced environment are essential
- Experience with transitions of care and care coordination is highly preferred
- Comfortable conducting face-to-face and home visits for high-risk members post-discharge