Care Transitions RN

The Care Transitions Registered Nurse (RN) coordinates patient care from the hospital/emergency department to home or another facility to lower readmission rates and ensure a safe transition and follow up. This position collaborates with patients, families, providers, and community resources to support safe transitions of care, improve patient outcomes, and reduce avoidable hospital admissions and readmissions.

Duties include but are not limited to:

1. Patient Assessment & Planning
   • Conduct assessments of high-risk patients to identify medical, social, and environmental risk factors.
   • Collaboration to develop a comprehensive discharge plan in partnership with patients, families, and physicians.
   • Develop individualized care plans focusing on medication management and follow-up care.
2. Care Coordination & Communication
   • Serve as a liaison between inpatient providers, primary care providers, specialists, and external health agencies.
   • Coordinate services including home health, durable medical equipment, remote patient monitoring, and pharmacy needs.
   • Collaboration with internal and external care teams
   • Other care coordinator duties as assigned
3. Patient & Family Education
   • Provide education on disease management, warning signs, and escalation protocols.
   • Review discharge instructions and medication schedules during post-discharge and emergency department follow-up calls.
   • Collaboration with patient and/or families in coordination of care

Hours/Shifts
80 hours biweekly, day shifts, Monday to Friday.

Compensation
Hourly wage range: $42.63 - $54.57. Please note that final compensation will be determined based on experience, qualifications and internal equity considerations.

Benefit Offerings
Lake Region Healthcare is pleased to offer a comprehensive benefit program designed to meet your unique needs. This includes medical and dental coverage; HSA, FSA and 401k plans; EAP, life and disability coverage; voluntary accident, critical illness and hospital indemnity coverage; pet insurance, ID theft protection and legal services. For new employees, the effective date of coverage for most plans is the first of the month, following a 30-day waiting period.

EEOC
Lake Region Healthcare provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.