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Astrana Health

. Contact patients and family members about SNF at Home options, eligibility, and enrollment .

Posted 9/21/2026full-timeJohnston • Rhode Island • United StatesMid-LevelSenior💰 $85,000 - $100,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in care coordination, patient engagement, and transition of care, with a strong focus on communication and relationship-building among patients, families, and healthcare professionals. Proficient in managing documentation and workflows to ensure exceptional patient and family experiences.

Highest-signal resume keywords

Registered Nurse (RN)Care CoordinationPatient EngagementTransition of CareMicrosoft Office Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Care CoordinationPatient EngagementTransition PlanningDocumentation ManagementOutreach CommunicationEnrollment CoordinationProblem-SolvingTime ManagementSchedulingHealthcare Service Delivery Models

Soft Skills

Interpersonal CommunicationOrganizational SkillsAttention to DetailProfessionalismAccountability

Tools & Technologies

Microsoft Office ApplicationsBasic Computer Systems

Certifications & Qualifications

Associate's Degree in NursingActive Registered Nurse (RN) License

Industry Keywords

Skilled Nursing Facility (SNF)Patient CareHealthcare ProvidersDischarge PlanningCare Transition Activities

About the role

Key responsibilities & impact

Contact patients and family members about SNF at Home options, eligibility, and enrollment
Educate patients and caregivers about skilled nursing-level care in the home
Serve as a point of contact throughout the transition process
Conduct outreach and follow-up communications
Coordinate transitions from hospitals or traditional SNFs into the SNF at Home program
Collaborate with clinical teams, case managers, discharge planners, SNF staff, and internal team members
Facilitate communication among patients, families, providers, facilities, and stakeholders
Assist with scheduling, transition planning, follow-up, and enrollment coordination
Identify transition barriers and escalate concerns
Conduct in-person visits at hospitals and Skilled Nursing Facilities throughout Rhode Island
Build relationships with discharge planners, case managers, SNF personnel, and healthcare providers
Represent the organization during onsite meetings and care transition activities
Document patient interactions, outreach, transition activities, and coordination notes
Track outreach, enrollment progress, and transition outcomes
Support reporting, workflows, administrative processes, team meetings, training, and special projects

Requirements

What you’ll need

Associate's degree in Nursing required
Registered Nurse (RN) required
Active Registered Nurse (RN) license required
Valid driver's license and reliable transportation required
Strong knowledge of care coordination, patient engagement, transition of care, and healthcare service delivery models
Excellent verbal, written, and interpersonal communication skills
Ability to communicate effectively with patients, caregivers, providers, facility staff, and healthcare professionals
Strong organizational and time management skills
Ability to work remotely and independently in a field-based environment
Strong problem-solving skills
Proficiency with Microsoft Office applications and basic computer systems
Ability to maintain accurate documentation and manage confidential information
High degree of professionalism, accountability, integrity, and attention to detail
Commitment to exceptional patient and family experiences

Benefits

Comp & perks

Hybrid work model combining remote work and field-based travel
Travel throughout Rhode Island to support hospitals, Skilled Nursing Facilities, patient visits, and care transition activities
Ability to attend meetings in person or virtually based on business needs
Use of computers, telephones, mobile devices, electronic documentation systems, and virtual communication tools
Reliable transportation and independent travel throughout the assigned territory
Compliance with organizational policies, patient privacy, HIPAA requirements, and applicable regulations