Clinical Support Re-admission Nurse; RN​/LPN

General Summary / Responsibilities

Oversee patient monitoring and outreach to reduce hospital readmission rates.

• 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.

• 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.

• 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.

• Serve as a clinical resource to field staff regarding high‑risk patients and readmission prevention strategies.
• 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.

Minimum Level of

Education Required:

Associate degree.

Type of degree: RN or LPN.

Area of study or major:
Nursing.

Preferred educational qualifications: NA.

Position specific testing requirement: NA.

Current Ohio RN or LPN license.

Minimum level of experience required: 1–3 years of job‑related experience.

Prior job title or occupational experience: 0.2 years of nursing experience required, preferably in home health, case management, care coordination, or chronic disease management.

Preferred experience:

Preferable home health but not mandatory. Will train the appropriate candidate.

Other experience requirements:
Customer service 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.