Registered Nurse (RN)- Discharge Care, Part-Time, Remote, Weekends

Prisma Health•Greenville, SC

1d•Remote

About The Position

This role is responsible for initiating phone contact with discharged patients to assess their experience and recovery, and to provide necessary follow-up. The Registered Nurse (RN) will coordinate patient responses requiring further intervention with the appropriate Nurse Manager and will work independently or under indirect supervision. The position focuses on supporting readmission prevention efforts by ensuring appropriate follow-up and addressing barriers to care, as well as reviewing and addressing open care gaps and educating patients on overdue screenings or visits.

Requirements

Associate degree in Nursing.
One (1) year experience as a registered nurse.
Holds a current RN compact/multistate license recognized by the NCSBN Compact State or is licensed to practice as an RN in the state the team member is working.

Nice To Haves

Bachelor's degree in Nursing preferred.
In lieu of an associate’s degree in nursing (AD N), will accept an RN diploma or certificate with a current RN compact/multistate license recognized by the NCSBN Compact State or a license to practice as an RN in the state the team member is working.

Responsibilities

Conduct non–face-to-face post-discharge outreach calls to patients within the CMS-required timeframe.
Review discharge summaries, medication lists, and follow-up instructions prior to patient contact.
Perform medication reconciliation and coordination support.
Assess patient understanding of discharge plan, symptom management, and medication adherence.
Record patient responses and advice provided, documenting any variations.
Provide appropriate follow up as indicated by patient responses and needs.
Identify early signs of potential complications and escalate concerns to the provider or care team.
Schedule appointments directly with the patient’s primary care provider, coordinating with front desk and clinical teams to secure timely appointment availability.
Document all outreach attempts, patient interactions, and outcomes in the EHR according to Prisma Health and CMS requirements.
Provide/Reinforce education provided at discharge, including when to contact the provider versus seek emergency care.
Support readmission prevention efforts by ensuring appropriate follow-up and addressing barriers to care.
Review and address open care gaps (e.g., hypertension control, diabetes monitoring, preventive screenings, wellness visits).
Educate patients on the importance of completing overdue screenings or visits and assist in scheduling.
Collaborate with providers, care coordinators, and case management teams to ensure continuity of care.
Participate in team discussions and quality improvement initiatives related to department effectiveness and patient outcomes.
Maintain awareness of required documentation and billing requirements to ensure compliance.
Provide hypertension-focused education on home blood pressure monitoring, medication adherence, lifestyle modifications, and follow-up importance.
Assess and intervene for elevated blood pressure readings or medication concerns by escalating to the provider and facilitating appropriate follow-up.
Collect patient data and complete required forms with appropriate responses according to the unit standards; identify patient's problems/needs and set priorities; identify problems requiring further referral and/or follow-up; observe and record latest diagnostic results; perform advanced nursing observations using critical thinking skills.
Develop a plan for follow up care based on nursing process, and which incorporate the plans of other disciplines and continuing or emerging care needs; include the patient/family in developing or revising plan.
Provide telephonic care advice and other follow up instructions according to patient care standards.
Demonstrate understanding of age-related characteristics and needs of patients served.
Explain nursing procedures and discharge teaching in appropriate forms.
Evaluate care measures instituted.
Identify situations that require immediate action and provide appropriate plan.
Understand and demonstrate respect for patient rights and confidentiality, and identify mechanisms for management of any ethical issues.
Perform other duties as assigned.