Registered Nurse (RN) - Care Transition Coordinator

Field Registered Nurse (RN)

Location: Marion County / Indianapolis, IN (Field-Based)

Company: DaMar Staffing Solutions of Indianapolis

Position Summary: DaMar Staffing Solutions is seeking a compassionate and organized Marion County Field Registered Nurse (RN) to support care transitions for individuals discharging from hospitals, nursing facilities, rehabilitation centers, and other inpatient settings into the community. This field-based role focuses on care coordination, patient advocacy, discharge planning, and reducing hospital readmissions through person-centered support services. The RN will collaborate with healthcare providers, case managers, LTSS Coordinators, caregivers, and community partners to ensure patients receive the resources and support needed for successful community-based care.

Key Responsibilities:

• Coordinate transitions of care for high-risk and post-acute patients.
• Conduct in-person, virtual, and telephonic outreach with patients, caregivers, and providers.
• Participate in discharge planning and interdisciplinary care coordination meetings.
• Complete clinical assessments and identify post-discharge needs including home health, transportation, behavioral health support, and community resources.
• Educate patients and families on care plans, medications, and follow-up care.
• Monitor high-risk members to reduce avoidable ER visits and hospital readmissions.
• Maintain accurate documentation in compliance with Medicaid, CMS, and NCQA standards.
• Support quality improvement initiatives and collaboration across healthcare and community-based organizations.

Qualifications:

• Active Indiana RN license in good standing.
• Minimum of 2 years of experience in transitional care, case management, home health, discharge planning, managed care, or related settings.
• Experience with Medicaid populations and behavioral health preferred.
• Strong communication, documentation, and care coordination skills.
• Reliable transportation and willingness to travel throughout Marion County up to 80%.

Compensation & Benefits:

• Competitive salary: $75,000 to $90,000
• Mileage reimbursement
• Health insurance and comprehensive benefits package
• Mission-driven and community-focused work environment

About DaMar Staffing Solutions: DaMar Staffing Solutions partners with healthcare organizations and community programs to support workforce development, care coordination, and improved health outcomes throughout Indiana communities.