Essential Duties: Works closely with families of diverse patient populations• Coordinates with Case Management/Care Coordination teams regarding readmission prevention• Assists with identification of patients at high risk for readmission• Proactive collaboration to facilitate discharge teaching for readmitted/high risk patients prior to or at discharge• Schedules post-discharge appointments• Develops patient-friendly discharge instructions• Performs handoffs (hospital to aftercare), medication reconciliation and education reinforcement• Supports the planning, implementation and evaluation of service delivery, patient experience, and care management activities• Coordinates with hospital staff to ensure accurate discharge summaries• Coordinates family/caregiver support, appropriate services and transitional support• Prioritizes duties and responsibilities, demonstrating strong organization and time management skills• Demonstrates excellent verbal and written communication skills, assuring appropriate confidentiality is always maintained• Interacts with others in a positive, professional manner, contributing to a positive team environment• Maintains administrative and medical records in a current and accurate manner, assuring all documentation requirements are met• Develops patient-centered discharge plan • Facilitates patient/family education• Communicates discharge plans and patient education needs with physician and care team members• In collaboration with patient, arranges post-discharge follow up appointment with primary care physician• Communicates important updates with patient's primary care provider, as appropriate• Reviews discharge instructions with patients• Requests additional interventions as indicated and appropriate• Answers telephone and greets patients, visitors, and employees in a helpful and appropriate manner• Demonstrates effective and efficient patient care in a professional and compassionate manner• Supports patient/family education regarding chronic disease management• Conducts initial post-discharge outreach to patients within a defined timeline• Active coordination and facilitation of patient management plans, as appropriate• Performs and documents medication reconciliation during outreach call if applicable• Oversees patient registries and proactive patient engagement strategies• As directed, may assist with respite and case management RN roles and responsibilities.• People Management/Department Management/BusinessUnit Management:• Supports nursing and physician leadership, as appropriate, with execution of initiatives, goals, and programs• Manages and supports the implementation of new initiatives and ensures coordination of strategy and initiatives• Provides support and subject matter expertise for complex organizational change efforts• Assists with the assessment of learning needs, develops competency plans and provides opportunities for learning• Facilitates consensus among divergent groups• High degree of knowledge and competency in the practice of nursing and documentation requirements• Demonstrates ability to anticipate and take a well-ordered and logical approach to analyzing problems, organizing work and planning action; gathering information and data before making decisions; and managing program/projects in a thorough and strategic manner• Functions with a high degree of interdependence while actively collaborating with other members of the health care team and departments• Strong commitment to quality, efficiency, and effectiveness• Manages multiple, complex diverse projects and programs• Proficient in applying Microsoft Office software tools in a systems environment• Adheres to all local, state, and federal regulations.