Readmission Prevention Coordinator (Registered Nurse)

As our Readmission Prevention Coordinator (Registered Nurse) , you’ll be at the heart of our mission to educate, enhance, empower. Think of yourself as both detective and coach—you’ll dig into data, spot trends, and uncover the “why” behind hospital readmissions. Then, you’ll turn those insights into smart, practical strategies that keep our patients healthier and out of the hospital. Your work will include tracking patterns, brainstorming new approaches to care, and teaming up with clinicians to deliver recommendations that are grounded in evidence but easy to act on. You’ll also have the chance to reimagine care protocols, helping us improve outcomes, elevate patient experiences, and celebrate every win against readmission. Remote Opportunity: All candidates must reside within California and have a valid CA RN license. How You’ll Make an Impact Collect and analyze patient data, including readmission statistics, to identify trends, patterns, and risk factors. Categorize and record common themes based on data from patient care records, helpline interactions, and clinical outcomes. Develop and propose data-driven alternatives to existing care protocols to address identified risks and prevent readmissions. Suggest adjustments and interventions to care teams that align with findings from data analysis and patient trends. Work closely with nursing, physical therapy (PT), occupational therapy (OT), speech therapy (ST), home health aides (HHA), social workers (SW), and other healthcare professionals to gather insights from their care experiences. Provide feedback to clinical staff based on data analysis to help refine patient care strategies. Collaborate with clinical and educational leaders to ensure that training programs are aligned with current data findings on disease management, medication adherence, and patient care practices. Suggest improvements to training and education materials based on observed trends and gaps in care protocols. Continuously monitor and evaluate the effectiveness of readmission prevention initiatives, identifying areas where care improvements can be made. Use data visualization tools such as Pareto charts to clearly communicate common causes of readmissions and suggest targeted interventions. Assist in developing new protocols or refining existing ones based on data analysis, focusing on addressing common causes of readmission. Ensure that protocol changes are well-documented and communicated to the relevant teams to enhance care outcomes. Ensure that all actions and data collection processes comply with federal, state, and local regulations regarding home healthcare and patient privacy. Prepare and submit detailed reports on readmission rates, preventive measures, and care improvements to senior management and external partners, such as Kaiser, within 24 hours of discharge when required. What Makes You a Great Fit Bachelor’s degree in Nursing (Master’s degree preferred). Valid and current CA nursing license. Minimum of 3 years of clinical experience, with at least 1 year in a home health or similar setting. Demonstrated experience in analyzing patient care trends and providing data-driven care recommendations. Strong analytical and problem-solving skills with the ability to interpret complex datasets. Excellent communication and collaboration skills for working with multidisciplinary teams. Commitment to improving patient outcomes through proactive data analysis and protocol improvements. Why You’ll Love Working Here Competitive salary and a comprehensive benefits package. The opportunity to be part of the 21HHS family , a team that is revolutionizing home healthcare in California by blending innovation with compassionate care. A warm, supportive culture where employees are truly treated like family. A mission-driven environment with abundant opportunities for professional growth and development. The chance to make a meaningful impact on patient outcomes and healthcare practices through forward-thinking, data-driven care improvements. $100,000 - $130,000 a year Enjoy the perks! From a competitive bonus plan to comprehensive healthcare, generous paid time off, and a 401(k) match up to 4%, we’ve got you covered—today and for the future. 21st Century is an equal opportunity employer, committed to fostering a diverse and inclusive workplace. We strictly prohibit discrimination or harassment of any kind, including but not limited to race, color, sex, religion, sexual orientation, gender identity, national origin, disability, genetic information, pregnancy, or any other characteristic protected under federal, state, or local law. #J-18808-Ljbffr