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. 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.
• 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