Care Transitions Registered Nurse (RN)

LAKE REGION HEALTHCARE•Fergus Falls, MN

6d•$43 - $55•Onsite

About The Position

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.

Requirements

Active, unrestricted RN license in the applicable state.
Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) from an accredited program.
Minimum of 2 years of clinical experience in acute care, discharge planning, home health, or case management.
Exceptional communication and interpersonal skills.
Strong critical thinking and problem-solving abilities.
Proficiency in electronic health record (EHR) documentation.

Nice To Haves

Care Transitions Certification (CTC) or case management certification preferred.

Responsibilities

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.
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
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