Clinical Support Re-admission Nurse (RN/LPN)

Clinical Support Re-admission Nurse RN/LPN

Patient Monitoring & Outreach Monitor and manage a daily high-risk patient list to identify patients at elevated risk for hospital readmission Conduct proactive outbound phone calls to high-risk patients to assess symptoms, medication compliance, and overall clinical status Provide disease-specific education, medication reinforcement, and self-management support during patient calls Identify early warning signs of clinical deterioration and escalate concerns appropriately Care Coordination Issues and treatment recommendations Coordinate care with home health field clinicians (RNs, LPNs, therapists, aides) to ensure timely follow-up and interventions Support transitions of care following hospital discharge to ensure continuity and understanding of the care plan Clinical Documentation & Compliance Document all patient interactions, assessments, and interventions accurately and timely in the electronic medical record Ensure compliance with agency policies, clinical protocols, and regulatory standards Participate in quality improvement initiatives focused on reducing hospital readmissions Collaboration & Team Support Serve as a clinical resource to field staff regarding high-risk patients and readmission prevention strategies. Will assist field staff in physician office contact Participate in interdisciplinary meetings or huddles related to high-risk patient management Promote a patient-centered, proactive care approach across the home health team

Qualifications Education Minimum Level of Education Required: Associate degree

Additional Requirements Type of degree: RN or LPN Area of study or major: Nursing Preferred educational qualifications: NA Position specific testing requirement: NA Licensure/Certification/Registration Current Ohio RN or LPN license

Experience Minimum Level of Experience Required: 1 - 3 years of job-related experience Prior job title or occupational experience:.2 years of nursing experience required, preferably in home health, case management, care coordination, or chronic disease management. Prior specific functional responsibilities N/A Preferred experience: Preferable Home Health but not mandatory. Will train the appropriate candidate Other experience requirements: customer service skills Knowledge/Skills Strong clinical assessment skills and ability to identify early signs of patient decline Excellent communication skills, particularly telephone-based patient engagement Ability to work independently, manage priorities, and handle a high-volume patient list

• Home health or post-acute care experience
• Experience working with high-risk or medically complex patients
• Familiarity with EMR systems and care coordination workflows
• Knowledge of readmission reduction strategies and chronic disease education