Float Home Health Care Transition Coordinator - RN required

Company: Ascension at Home together with Compassus Position Summary Registered Nurse required. This is a Float role covering St. Johns, Riverside, Southside and Clay County hospitals. Monday - Friday, 8AM - 5PM. Role Overview The Float Home Health Care Transition Coordinator models Compassus values of Compassion, Integrity, Excellence, Teamwork, and Innovation. The Coordinator serves as a trusted resource for physicians, hospital case managers, and referral sources, facilitating skilled conversations and ensuring patients receive appropriate post‑acute care. Position Specific Responsibilities Meet regularly with physicians to discuss patients, providing guidance for post‑acute service support and ensuring continuity of care. Act as hospital case manager, performing high‑risk patient reviews and rounding in step with hospital teams. Support transition to home health, home infusion, and hospice services through in‑person bedside transitions. Educate patient families and referral sources on hospice, home infusion, and home health benefits. Develop collegial relationships with Ascension professionals, meeting clinicians to problem‑solve and review cases. Interact with difficult patients/families, identifying steps for successful family meetings. Maintain a current list of admission coordinators for each service line. Align recommendations between patient/family and Primary Care team: identify preferences, post‑acute needs, level of care, educate on Homebound criteria, and facilitate transition planning. Set patient‑centered goals and arrange home admission, communicating with Home Health and Home Infusion teams. Coordinate patient care by obtaining H&P, physician orders, hospital records, and documenting promptly. Verify patient demographic information and coordinate organization of transfer orders, educating on home care orders and services. Identify 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. Develop analytical skills for claims data and predictive analytics. Ensure excellent customer service and continuously improve knowledge and sales skills to add value. Meet or exceed assigned quotas, maintaining and constantly improving Home Health’s competitive position. Perform other duties as assigned. Education and Experience Bachelor’s degree preferred. Two (2) to three (3) years of RN experience required. Hospital and/or long‑term care clinical experience highly preferred. Experience with home health eligibility admission requirements, COPs, PDGM knowledge and training, risk scoring/data analysis, end‑of‑life practices, homebound status determination, palliative care, General Dx and LCDs, and prognosis communication preferred. Skills Mathematical: add, subtract, multiply, divide in all units of measure, using whole numbers, common fractions, and decimals. Compute rate, ratio, and percentage. Language: read, analyze, and interpret business periodicals, professional journals, technical procedures, or governmental regulations. Write reports, business correspondence, and procedure manuals. Present information effectively and respond to questions from leaders, team members, investors, and external parties. Strong written and verbal communication. Other: 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 Regular standing, walking, manual dexterity are fundamental. Ability to lift and move objects up to 50 pounds. Visual acuity requirements include close, distance, color, and peripheral vision, depth perception, and ability to adjust focus. Exposure to bodily fluids, infectious diseases, and typical healthcare conditions is expected. Routine use of standard medical equipment and tools associated with clinical care is essential. Benefits Meaningful work: impact patients and families with compassion. Career development: leadership pathways, mentorship, personalized professional development. Innovation meets compassion: supportive team using latest tools and technologies. Enhanced benefits: competitive pay, flexible time off, tuition reimbursement, wellness programs. Recognition and support: programs honoring contributions. Culture of belonging: authentic self, valued for unique contributions, supported in diversity and inclusion. Equal Opportunity Employer At Compassus, including all Compassus affiliates, diversity, equity, and inclusion are fundamental. We are committed to creating a fair work environment where all team members feel welcomed, highly valued, and respected. As an equal‑opportunity employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, genetics, disability, age, or veteran status. #J-18808-Ljbffr