RN Post-Acute Coordinator - South

INTEGRIS Health•Oklahoma City, OK

6d•Onsite

About The Position

INTEGRIS Health is seeking a full-time, day-shift RN Post-Acute Coordinator at INTEGRIS Health South Medical Center in Oklahoma City. The coordinator serves as a liaison between inpatient case managers and the health system’s ambulatory services. The role identifies patients with referral-sensitive needs, initiates service-line referrals, and coordinates transitions to internal services such as home health, hospice, durable medical equipment (DME), outpatient therapy, sleep medicine, pharmacy, and follow-up care with the employed medical group. The coordinator reports to the Director of Ambulatory Operations and is responsible for referral conversions, case manager satisfaction, and troubleshooting barriers to discharge.

Requirements

RN with 3+ years of experience 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 patients for eligibility across 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 about next steps and what to expect after discharge.
Track referral status and ensure service activation before discharge.
Collaborate with case managers and physicians to prevent discharge delays.
Document interventions and outcomes in the EHR.
Support referral conversions, case manager satisfaction, and resolution of barriers to discharge.