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.

Work Shift

Day (United States of America)

Location

Corporate

Facility

7002 Value-Based Care and Network Services

Department

70029261 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.