Home Health Care Transition Coordinator - Infusion Registered Nurse Required

Position Summary Registered Nurse required with infusion experience. Role primarily based at Seton Main Hospital and will float to Dell Seton Medical Center. Monday – Friday, 8:00AM – 5:00PM. Responsibilities Meet regularly with physicians in the hospital to discuss specific patients, provide guidance on post‑acute service support, and ensure continuity of care. Act as a hospital case manager, participating in rounds or step‑in interactions to review high‑risk patients. Support transitions to home health, home infusion, and hospice services through in‑person bedside transitions when services are offered. Educate patients, families, and referral sources on hospice, home infusion, and home health benefits. Develop collegial relationships with Ascension professionals and meet regularly with clinicians to problem‑solve and review cases. Identify steps for successful family meetings and communicate patient/family preferences and needs. Maintain a current list of admission coordinators for each healthcare service line and align recommendations between the patient/family and primary care team. Assess post‑discharge needs, develop and implement a transition‑to‑home plan, and set patient‑centered goals. Coordinate patient care by obtaining H&P, physician orders, hospital records, and documentation promptly. Verify patient demographic information and ensure it is correct. Educate patients on home‑care orders and services, and identify the primary care physician to follow the plan of care. Conduct follow‑up on re‑hospitalized home‑health patients and participate in re‑hospitalization mitigation strategies. Use claims data, predictive analytics, and risk scoring to support reporting and improve customer service. Meet or exceed assigned quotas and continually develop knowledge and sales skills. Perform other duties as assigned. Qualifications Bachelor’s degree preferred. 2 to 3 years of RN experience required. Hospital and/or long‑term care clinical experience highly preferred. Knowledge of infusion home health eligibility, COPs, PDGM, risk scoring, palliative care, hospice philosophy, homebound status determination, general diagnoses and LCDs, and disease trajectory communication preferred. Skills and Abilities Mathematical: add, subtract, multiply, and divide in all units; calculate rate, ratio, and percentage. Language: read, analyze, and interpret business periodicals, professional journals, technical procedures, and regulations; write reports, correspondence, and procedure manuals; present information effectively. Strong verbal and written communication skills. Ability to understand, read, write, and speak English. Articulate and embrace hospice philosophy. Certifications, Licenses, and Registrations Active and unencumbered Registered Nurse license in the state(s) of employment required. Physical Demands and Work Environment The role requires regular standing, walking, and manual dexterity, including lifting and moving objects up to 50 pounds. Visual acuity is required for close, distance, color, peripheral, and depth perception, with the ability to adjust focus. Exposure to bodily fluids, infectious diseases, and conditions typical to the field is expected. Routine use of standard medical equipment and tools associated with clinical care is essential. Equal Employment Opportunity Statement We are an equal‑opportunity employer. All qualified applicants will receive consideration for employment regardless of race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. #J-18808-Ljbffr Compassus