Readmissions Coordinator

Position Summary

As a Readmissions Coordinator the goal is to reduce unnecessary hospital readmissions by coordinating patient care and developing post-discharge transition plans. Key responsibilities include assessing patient needs, creating and implementing care plans, connecting patients with community resources, and providing support to ensure successful transitions back home. They act as a liaison between the patient, their family, physicians, and other healthcare providers, monitor progress, and ensure patients have the necessary services and support to maintain their health and avoid future hospitalizations.

• Outreach to patients before elective procedures to provide education and identify and address any potential barriers before surgery.
• Collaborate with medical and clinical staff to enhance the quality and completeness of clinical documentation, ensuring a seamless discharge plan.
• Collaborate with the patient, family, and the interdisciplinary team (doctors, nurses, therapists) to create a comprehensive discharge and transition plan.
• Ensure accurate capture of Hierarchical Condition Categories (HCC) by the Primary Care Providers and Specialists/Surgeons before surgery.
• Arrange for post-discharge services such as home health, therapy, and physician appointments. They also navigate insurance benefits and authorizations.
• Attend multidisciplinary rounds with the case management team.
• Round on patients discharged from HMC in subacute rehabilitation facilities to ensure they are meeting their care goals.
• Engaged patients, families, and caregivers in the care coordination and discharge planning process, updating the plan as conditions changed and communicating changes to the healthcare team.
• Plan and facilitate a safe discharge plan with input from patients, family, caregivers, and the healthcare team, coordinating benefits and utilizing outpatient treatments, therapies, specialty and primary care practices, and community resources to optimize the integrated delivery of the healthcare system and documenting these plans in the patient's EMR.
• Follow up with patients after discharge to check on their progress, ensure their satisfaction with services, and make adjustments to their plan as needed.
• Engaged patients, family, and caregivers in the discharge planning process to promote self-management of chronic disease conditions.
• Supported organizational objectives of Service Excellence, Critical Success Factors, and High Reliability Organization standards.

All hires after July 2012 are required to have a Bachelors Degree in nursing. Alternatively, an Associate's Degree or Diploma is held. In that case, the RN must provide proof of enrollment in a BSN program before hire, be continuously enrolled, and complete it within 5 years of the hire date or internal RN promotion date.

Three (3) years of medical/surgical hospital-based direct patient care experience.

Five (5) years of medical/surgical hospital-based direct patient care experience and experience with Case Management.

Current NJ RN Licensure.

Case Management Certification.

Excellent verbal and written communication skills are essential for interacting with patients, families, and healthcare teams. The role requires strong organizational skills, attention to detail, and the ability to manage a caseload effectively. Ability to identify barriers to a patients success and develop creative solutions. Proficiency in working collaboratively with a variety of professionals and community partners. Maintain accurate and timely records, case notes, and reports.

Familiarity with case management software and electronic health records is often required.

Hunterdon Health is committed to providing a competitive benefit package to our employees. Benefit offerings vary based on status and may include but not be limited to medical, dental, vision, family forming, paid time off, tuition reimbursement, and retirement savings.

The hiring range listed is the potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement. When determining an applicant’s hourly rate and/or base salary, several factors may be considered as applicable (e.g., years of relevant experience, education, internal equity, and specialty).