RN Post-Acute Coordinator - South

Join our team as a day shift, full time, RN Post Acute Coordinator, at INTEGRIS Health South Medical Center, in Oklahoma City.

Get to Know Your Team:

• INTEGRIS Health, Oklahoma's largest not-for-profit health system, is seeking a dedicated caregiver to join us in our mission to partner with people to live healthier lives.

• Benefits of being an INTEGRIS Health caregiver include front-loaded PTO, medical benefits through the extensive INTEGRIS Health network, financial assistance for continued education, 24/7 mental health support and more.

• Take the first step toward growing your career by joining us.

INTEGRIS Health mission: Partnering with people to live healthier lives.

To our patients, that means we will partner to provide unprecedented access to quality and compassionate health care. To you, it means some of the state''s best career and development opportunities. With INTEGRIS Health, you will have a genuine chance to make a difference in your life and your career.

INTEGRIS Health is the state''s largest Oklahoma-owned health system with hospitals, rehabilitation centers, physician clinics, mental health facilities and home health agencies throughout much of the state.

• RN with 3+ years in care coordination or ambulatory services
• Familiarity with Medicare/Medicaid eligibility for home health and DME
• Strong communication and organizational skills
• Ability to collaborate across clinical and operational teams
• Proficiency in EHRs and referral management platforms

The clinical post-acute coordinator is a liaison between inpatient case managers and the health system's suite of ambulatory services. The post-acute coordinator is responsible for identifying patients with referral-sensitive needs, initiating service line referrals, and coordinating transitions to internal services including home health, hospice, DME, outpatient therapy, sleep medicine, pharmacy, and follow-up care with the employed medical group.

The Post-Acute Coordinator responsibilities include, but are not limited to, the following:

• Participate in daily interdisciplinary rounds to identify referral-sensitive patients
• Screen for eligibility across all internal ambulatory services
• Coordinate referrals with home health, hospice, DME, therapy, wound care, and pharmacy intake teams
• Directly schedule follow-up primary and specialty care appointments with employed physicians
• Educate patients and families on next steps and what to expect post-discharge
• Track referral status and ensure service activation prior to discharge
• Collaborate with case managers and physicians to prevent discharge delays
• Document interventions and outcomes in the EHR

The clinical post-acute Coordinator will report to the Director of Ambulatory Operations and be responsible for referral conversions, case manager satisfaction, and troubleshooting barriers to discharge.

The clinical post-acute coordinator is a liaison between inpatient case managers and the health system's suite of ambulatory services. The post-acute coordinator is responsible for identifying patients with referral-sensitive needs, initiating service line referrals, and coordinating transitions to internal services including home health, hospice, DME, outpatient therapy, sleep medicine, pharmacy, and follow-up care with the employed medical group.

The Post-Acute Coordinator responsibilities include, but are not limited to, the following:

• Participate in daily interdisciplinary rounds to identify referral-sensitive patients
• Screen for eligibility across all internal ambulatory services
• Coordinate referrals with home health, hospice, DME, therapy, wound care, and pharmacy intake teams
• Directly schedule follow-up primary and specialty care appointments with employed physicians
• Educate patients and families on next steps and what to expect post-discharge
• Track referral status and ensure service activation prior to discharge
• Collaborate with case managers and physicians to prevent discharge delays
• Document interventions and outcomes in the EHR

The clinical post-acute Coordinator will report to the Director of Ambulatory Operations and be responsible for referral conversions, case manager satisfaction, and troubleshooting barriers to discharge.