Registered Nurse - Discharge Care Part-Time Remote Weekends

**Inspire health. Serve with compassion. Be the difference.** **Job Summary** Responsibility for initiating phone contact with discharged patients from specified units, conducting query on patient experience and recovery, and providing needed follow up to patients and/or family members. Coordinates patient responses requiring further intervention with appropriate Nurse Manager. Works independently and/or under indirect supervision of the Nurse Manager. **Essential Functions** * All team members are expected to be knowledgeable and compliant with Prisma Health's purpose:  Inspire health.  Serve with compassion.  Be the difference. * Conduct non–face-to-face post-discharge outreach calls to patients within the CMS-required timeframe. * Review discharge summaries, medication lists, and follow-up instructions prior to patient contact. * Medication reconciliation and coordination support. * Assess patient understanding of discharge plan, symptom management, and medication adherence. * Records patient responses and advice provided, documents any variations. Provides appropriate follow up as indicated by patient responses and needs. * Identify early signs of potential complications and escalate concerns to the provider or care team. * Schedule appointments directly with the patient’s primary care provider. * Coordinate with front desk and clinical teams to secure timely appointment availability. * Document all outreach attempts, patient interactions, and outcomes in the EHR according to Prisma Health and CMS requirements. * Provide/Reinforce education provided at discharge, including when to contact the provider versus seek emergency care. * Support readmission prevention efforts by ensuring appropriate follow-up and addressing barriers to care. * Review and address open care gaps (e.g., hypertension control, diabetes monitoring, preventive screenings, wellness visits). * Educate patients on the importance of completing overdue screenings or visits and assist in scheduling. * Collaborate with providers, care coordinators, and case management teams to ensure continuity of care. * Participate in team discussions and quality improvement initiatives related to department effectiveness and patient outcomes. * Maintain awareness of required documentation and billing requirements to ensure compliance. * Provide hypertension-focused education on home blood pressure monitoring, medication adherence, lifestyle modifications, and follow-up importance. * Assess and intervene for elevated blood pressure readings or medication concerns by escalating to the provider and facilitating appropriate follow-up. * Collects patient data and completes required forms with appropriate responses according to the unit standards; identifies patient's problems/needs and sets priorities; identifies problems requiring further referral and/or follow-up; observes and records latest diagnostic results; performs advanced nursing observations using critical thinking skills. * Develops a plan for follow up care based on nursing process, and which incorporate the plans of other disciplines and continuing or emerging care needs; include the patient/family in developing or revising plan. * Care provided conforms to accepted practice standards; provides correct telephonic care advice and other follow up instructions according to patient care standards; demonstrates understanding of age-related characteristics and needs of patients served; explains nursing procedures and discharge teaching in appropriate forms; evaluates care measures instituted; identifies situations that require immediate action and provides appropriate plan; understands and demonstrates respect for patient rights and confidentiality, and identifies mechanism for management of any ethical issues. * Performs other duties as assigned. **Supervisory/Management Responsibilities** * This is a non-management job that will report to a supervisor, manager, director or executive. **Minimum Requirements** * Education - Associate degree in Nursing. Bachelor's degree in Nursing preferred. * Experience - One (1) year experience as a registered nurse. **In Lieu Of** * In lieu of an associate’s degree in nursing (AD N), will accept an RN diploma or certificate with a current RN compact/multistate license recognized by the NCSBN Compact State or a license to practice as an RN in the state the team member is working. **Required Certifications, Registrations, Licenses** * Holds a current RN compact/multistate license recognized by the NCSBN Compact State or is licensed to practice as an RN in the state the team member is working. **Knowledge, Skills and Abilities** * N/A **Work Shift** Weekend Shift (United States of America) **Location** Prisma Health Corporate Office **Facility** Value-Based Care and Network Services **Department** Ambulatory Quality and Reliability Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.