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RN Care Integration Specialist

Fort Hudson Health System, Inc.

  • Location: Fort Edward, NY
  • Post Date: 4/26/2019
  • Job Type: FULL TIME
The primary function of the position is to support the further development of an integrated model of care across multiple service settings; provide support and guidance during transition periods; arrange appropriate post-discharge services and care management support as necessary.
Primary Duties and Functions:

Act as primary point of contact for eligible patients utilizing select Fort Hudson programs following hospitalization during service period.
Collaborate with care providers in acute and post-acute settings to assure seamless transitions of care, coordinated service planning, and active engagement with care management services in the community
Conduct on-site or in-home visits of eligible patients during post-acute treatment periods at specified intervals to support continuity and communication
Conduct in-hospital visits during an rehospitalization or as otherwise indicated of eligible patients
Maintain detailed data and roster reports; identify additional data points as indicated which support the improved care outcome goals


Minimum of 2 years’ experience as a Registered Nurse required. One or more years experience as RN in home care setting preferred. Prior relevant experience in care management or similar role; experience in linking services and programs for community-based services to support individual’s independence in the community.
Must have valid NYS driver’s license; free of disqualifying offenses; reliable transportation capable of traveling in excess of two (2) hours at a time.
Fort Hudson Health System, Inc.