This role centers on nursing support for members transitioning between care settings, with a focus on helping patients move safely after discharge and stay connected to needed follow-up care. The work is likely care coordination-oriented rather than hands-on bedside treatment, with attention to ongoing needs, care plans, and communication across providers.
Key Responsibilities
- Coordinate transition-of-care support for members moving between inpatient and outpatient settings.
- Provide follow-up outreach to help members understand discharge instructions and next steps.
- Support care plan development and coordination with providers, facilities, and other care team members.
- Monitor member needs for ongoing services, referrals, and continuity of care.
- Document case management activities and member interactions in the appropriate systems.
Required
- Registered Nurse (RN) licensure.
- Experience in care coordination, case management, or transition-of-care support.