Clinical Support Re-admission Nurse (RN/LPN)

Premier Health•Dayton, OH

18h

About The Position

The Clinical Support Re-admission Nurse (RN/LPN) will monitor and manage a daily high-risk patient list to identify patients at elevated risk for hospital readmission. This role involves conducting proactive outbound phone calls to high-risk patients to assess symptoms, medication compliance, and overall clinical status. The nurse will provide disease-specific education, medication reinforcement, and self-management support during these calls, identifying early warning signs of clinical deterioration and escalating concerns appropriately. Additionally, the role includes care coordination with home health field clinicians, supporting transitions of care after hospital discharge, and ensuring accurate and timely documentation in the electronic medical record. The nurse will also serve as a clinical resource to field staff and participate in interdisciplinary meetings.

Requirements

Current Ohio RN or LPN license
Associate degree in Nursing
1 - 3 years of job-related experience
2 years of nursing experience required, preferably in home health, case management, care coordination, or chronic disease management.
Strong clinical assessment skills and ability to identify early signs of patient decline
Excellent communication skills, particularly telephone-based patient engagement
Ability to work independently, manage priorities, and handle a high-volume patient list
Customer service skills

Nice To Haves

Home health or post-acute care experience
Experience working with high-risk or medically complex patients
Familiarity with EMR systems and care coordination workflows
Knowledge of readmission reduction strategies and chronic disease education

Responsibilities

Monitor and manage a daily high-risk patient list to identify patients at elevated risk for hospital readmission.
Conduct proactive outbound phone calls to high-risk patients to assess symptoms, medication compliance, and overall clinical status.
Provide disease-specific education, medication reinforcement, and self-management support during patient calls.
Identify early warning signs of clinical deterioration and escalate concerns appropriately.
Coordinate care with home health field clinicians (RNs, LPNs, therapists, aides) to ensure timely follow-up and interventions.
Support transitions of care following hospital discharge to ensure continuity and understanding of the care plan.
Document all patient interactions, assessments, and interventions accurately and timely in the electronic medical record.
Ensure compliance with agency policies, clinical protocols, and regulatory standards.
Participate in quality improvement initiatives focused on reducing hospital readmissions.
Serve as a clinical resource to field staff regarding high-risk patients and readmission prevention strategies.
Assist field staff in physician office contact.
Participate in interdisciplinary meetings or huddles related to high-risk patient management.
Promote a patient-centered, proactive care approach across the home health team.