Clinical Support Re-admission Nurse (RN/LPN)

Clinical Support Re-admission Nurse

RN/LPN

General Summary/Responsibilities

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
  
  

Preferred

• 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