About the role
Under general supervision, provides patient education, support, and interventions to optimize care transitions. Assists in Plan of Care compliance. Includes coordination of Home Health, Remote Patient Monitoring (RPM), Durable Medical Equipment, Pharmacy as needed and communication with physicians. Uses a process of nursing intake, assessment, planning, and care in accordance with physician orders, the established plan of care, the patient’s diagnosis, policies and procedures, and the Nurse Pra…