Registered Nurse (RN)- Population Health, Remote, Full-Time, Days

• 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

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.