Post-Acute Coordinator -Southwest Medical Center

Integris Health • Oklahoma City, OK

88d

About The Position

The clinical post-acute coordinator is a liaison between inpatient case managers and the health system's suite of ambulatory services. The post-acute coordinator is responsible for identifying patients with referral-sensitive needs, initiating service line referrals, and coordinating transitions to internal services including home health, hospice, DME, outpatient therapy, sleep medicine, pharmacy, and follow-up care with the employed medical group.

Requirements

• RN with 3+ years in care coordination or ambulatory services
• Familiarity with Medicare/Medicaid eligibility for home health and DME
• Strong communication and organizational skills
• Ability to collaborate across clinical and operational teams
• Proficiency in EHRs and referral management platforms

Responsibilities

• Participate in daily interdisciplinary rounds to identify referral-sensitive patients
• Screen for eligibility across all internal ambulatory services
• Coordinate referrals with home health, hospice, DME, therapy, wound care, and pharmacy intake teams
• Directly schedule follow-up primary and specialty care appointments with employed physicians
• Educate patients and families on next steps and what to expect post-discharge
• Track referral status and ensure service activation prior to discharge
• Collaborate with case managers and physicians to prevent discharge delays
• Document interventions and outcomes in the EHR

What This Job Offers

• Industry: Hospitals
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees