LTSS RN Coordinator

Job Description

Job Description

Position Summary:

DaMar Staffing Solutions is seeking a compassionate and highly skilled LTSS RN Coordinator– Clinicians to support individuals transitioning from inpatient settings such as emergency departments, hospitals, skilled nursing facilities, or nursing homes. This role is critical in facilitating person-centered care planning and ensuring continuity of care during transitions. The LTSS RN Coordinator serves as a clinical liaison and advocate for patients, working closely with LTSS Coordinators, contracted providers, and interdisciplinary teams to promote safe, efficient, and high-quality care.

This position focuses on building trusting relationships with members and their families, preventing unnecessary readmissions, providing geriatric support, and optimizing the use of healthcare resources.

Key Responsibilities:

• Conduct in-person, virtual, and/or telephonic outreach to patients, providers, and stakeholders involved in transitions of care.
• Serve as a patient advocate to resolve barriers and ensure access to needed services and resources.
• Collaborate with LTSS service coordinators and clinical teams to identify risks and ensure alignment with the Person-Centered Service Plan (PCSP).
• Engage hospital staff (e.g., physicians, case managers, discharge planners) to support timely, safe discharges and effective post-acute care planning.
• Participate in case reviews, discharge planning meetings, and facilitate communication across the care continuum.
• Assist with reviewing medical records and utilization data to ensure appropriate care and identify discharge barriers.
• Provide education and support to patients and families regarding care plans, discharge instructions, medications, follow-up care, and available community resources.
• Complete structured clinical assessments to determine post-discharge needs including medical equipment, follow-up appointments, home health services, and caregiver support.
• Ensure documentation and tracking of transition interventions comply with internal protocols and external regulatory requirements (CMS, NCQA, state-specific).
• Report critical incidents to appropriate regulatory or state agencies when needed.
• Participate in member grievance or appeals processes, audits, and hearings as necessary.
• Offer mentorship and training to new staff as needed and support quality improvement efforts.

Minimum Qualifications:

• Active Registered Nurse (RN) license in the state of Indiana and in good standing.
• At least 2 years of clinical experience in transitional care, emergency department, discharge planning, or home health settings.

Preferred Qualifications:

• Strong knowledge of Medicaid, NCQA standards, and transitions of care protocols.
• Familiarity with inpatient care management and utilization review processes.
• Reliable transportation and willingness to travel up to 80% of the time within a designated regional territory (Monday–Friday, 8 AM–5 PM).
• Company will hire RNs working in the following counties: Marion, Lake, Union, Vanderburgh, Allen, Floyd
• Strong communication skills and ability to engage with diverse stakeholders, including patients, families, and healthcare teams.
• Ability to identify cost-effective care strategies that support high-quality outcomes.
• Proficient with documentation and clinical recordkeeping systems.
• Independent problem-solving skills and a proactive, patient-centered approach.
• Starting Salary $75,000 to $90,000 based on year of experience, mileage reimbursement; competitive health insurance and benefits.

Company DescriptionDaMar Staffing Solutions of Indianapolis (“DaMar”) is a premier boutique recruitment firm. The DaMar model offers on demand solutions at an affordable price. DaMar Staffing Solutions is the place for professional level staffing for all industries .

Company Description

DaMar Staffing Solutions of Indianapolis (“DaMar”) is a premier boutique recruitment firm. The DaMar model offers on demand solutions at an affordable price. DaMar Staffing Solutions is the place for professional level staffing for all industries .