Care Transition Specialist

• Area of Interest: Nursing

• FTE/Hours per pay period: 1.0

• Department: Call Center

• Shift: Day Shift- 0800-1630 CST, holiday and weekend rotation

• Job ID: 189213

Overview

RN Care Coordinator - Remote

Day Shift- 8a-4:30p CST, holiday and weekend rotation

Full-time benefits

As an RN Care Coordinator – Transition Care, you’ll play an important role in helping patients successfully transition from one healthcare setting to the next—most often from the hospital back home. As part of a collaborative, centralized team, you’ll use your nursing expertise to identify patient needs, coordinate services, and help ensure patients have the support and resources needed for a safe and successful recovery.

You’ll provide telephonic care coordination, complete medication reconciliation and assessments, connect patients with appropriate resources, and provide education to promote better health outcomes. If you enjoy building relationships, coordinating care, and making a meaningful difference in patients’ lives, this is an opportunity to make an impact beyond the traditional clinic setting.

Why UnityPoint Health?

At UnityPoint Health, you matter. We’re proud to be recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare several years in a row for our commitment to our team members.

Our competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you’re in.   Here are just a few:    

• Expect paid time off, parental leave, 401K matching and an employee recognition program .

• Dental and health insurance, paid holidays, short and long-term disability and more. We even offer pet insurance for your four-legged family members.

• Early access to earned wages with Daily Pay, tuition reimbursement to help further your career and adoption assistance to help you grow your family .

With a collective goal to champion a culture of belonging where everyone feels valued and respected, we honor the ways people are unique and embrace what brings us together.  

And, we believe equipping you with support and development opportunities is a vital part of delivering an exceptional employment experience.

Find a fulfilling career and make a difference with UnityPoint Health.

Responsibilities

• Support safe, effective transitions of care by conducting timely post-discharge outreach and assessments for high-risk patient populations.

• Manage Epic work queues and coordinate outbound calls to ensure patients receive appropriate follow-up , education, and resources after discharge.

• Identify patient needs and connect individuals to appropriate services, including care management, home health, hospice, disease management, and community resources.

• Provide education on chronic disease management, medications, and appropriate care settings to reduce preventable ED visits and readmissions.

• Collaborate with providers and care teams to support referrals, care planning, and continuity across the care continuum.

• Document all outreach, assessments, and care coordination activities accurately and in a timely manner within the EMR.

• Adapt to changing call volume and operational needs, including triage support, scheduling flexibility, and weekend/holiday rotation.

• Participate in process improvement initiatives and support organizational transformation efforts to enhance patient outcomes.

• Demonstrate clinical judgment, professionalism, and accountability while maintaining RN scope of practice.

• Contribute to a collaborative, high-performing team culture focused on continuous learning, innovation, and patient-centered care.

Qualifications

• Registered Nurse (RN) – Active/Unencumbered RN license in state of practice or compact license including state of practice.

• At least 1 year of clinical experience in home care and/or ambulatory care.

• Prior experience in a clinical or outpatient setting preferred

• Familiarity with EPIC a plus!