Readmission Prevention Coordinator, Registered Nurse

21st Century Home Health Services

Readmission Prevention Coordinator at 21HHS analyzing patient data to implement strategies preventing hospital readmissions. Collaborates with diverse healthcare professionals to enhance patient care.

Posted 5/20/2026full-timeRemote • California • 🇺🇸 United StatesMid-LevelSenior💰 $100,000 - $130,000 per yearWebsite

About the role

Key responsibilities & impact

Collect and analyze patient data, including readmission statistics, to identify trends, patterns, and risk factors.
Categorize and record common themes based on data from patient care records, helpline interactions, and clinical outcomes.
Develop and propose data-driven alternatives to existing care protocols to address identified risks and prevent readmissions.
Suggest adjustments and interventions to care teams that align with findings from data analysis and patient trends.
Work closely with nursing, physical therapy (PT), occupational therapy (OT), speech therapy (ST), home health aides (HHA), social workers (SW), and other healthcare professionals to gather insights from their care experiences.
Provide feedback to clinical staff based on data analysis to help refine patient care strategies.
Collaborate with clinical and educational leaders to ensure that training programs are aligned with current data findings on disease management, medication adherence, and patient care practices.
Suggest improvements to training and education materials based on observed trends and gaps in care protocols.
Continuously monitor and evaluate the effectiveness of readmission prevention initiatives, identifying areas where care improvements can be made.
Use data visualization tools such as Pareto charts to clearly communicate common causes of readmissions and suggest targeted interventions.
Assist in developing new protocols or refining existing ones based on data analysis, focusing on addressing common causes of readmission.
Ensure that protocol changes are well-documented and communicated to the relevant teams to enhance care outcomes.
Ensure that all actions and data collection processes comply with federal, state, and local regulations regarding home healthcare and patient privacy.
Prepare and submit detailed reports on readmission rates, preventive measures, and care improvements to senior management and external partners, such as Kaiser, within 24 hours of discharge when required.

Requirements

What you’ll need

Bachelor’s degree in Nursing (Master’s degree preferred).
Valid and current CA nursing license.
Minimum of 3 years of clinical experience, with at least 1 year in a home health or similar setting.
Demonstrated experience in analyzing patient care trends and providing data-driven care recommendations.
Strong analytical and problem-solving skills with the ability to interpret complex datasets.
Excellent communication and collaboration skills for working with multidisciplinary teams.
Commitment to improving patient outcomes through proactive data analysis and protocol improvements.

Benefits

Comp & perks

Competitive salary and a comprehensive benefits package.
The opportunity to be part of the 21HHS family, a team that is revolutionizing home healthcare in California by blending innovation with compassionate care.
A warm, supportive culture where employees are truly treated like family.
A mission-driven environment with abundant opportunities for professional growth and development.
The chance to make a meaningful impact on patient outcomes and healthcare practices through forward-thinking, data-driven care improvements.

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

data analysisdata visualizationpatient care analysisprotocol developmenttrend identificationrisk factor analysisreadmission statisticscare protocol adjustmentsclinical outcome assessmentdata-driven recommendations

Soft Skills

analytical skillsproblem-solving skillscommunication skillscollaboration skillsinterpersonal skillscommitment to patient outcomesfeedback provisiontraining program alignmentmonitoring and evaluationinsight gathering

Certifications

Bachelor’s degree in NursingMaster’s degree in Nursing (preferred)CA nursing license