What are the responsibilities and job description for the Clinical Support Re-admission Nurse (RN/LPN) position at Premier Health Partners?
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
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
- 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