Readmission Prevention Coordinator (Registered Nurse)

At 21st Century Home Health Services (21HHS), we treat every patient with the same empathy, compassion, and understanding we would show our own family. With more than 600 employees, we are the largest home health agency in San Francisco and the fastest-growing in the Bay Area. Today, we care for more than 4,000 patients across San Francisco, San Mateo, Santa Clara, Santa Cruz, Alameda, Contra Costa, Solano, Napa, Yolo, Placer, El Dorado, and Sacramento counties—and we are actively expanding into Marin and Sonoma counties. Our clinicians are dedicated not only to the patients they serve, but also to one another. The results speak for themselves: hospital readmission rates at 21HHS consistently remain under 10%, compared to an industry average of over 15%. We’ve also set a new benchmark for employee satisfaction in home health. Recognized as a 2024 Top Workplace, 21HHS fosters an environment of support, growth, and recognition through open communication and professional development opportunities.

As our Readmission Prevention Coordinator (Registered Nurse), you’ll be at the heart of our mission to Educate, Enhance, Empower. Think of yourself as both detective and coach—you’ll dig into data, spot trends, and uncover the “why” behind hospital readmissions. Then, you’ll turn those insights into smart, practical strategies that keep our patients healthier and out of the hospital. Your work will include tracking patterns, brainstorming new approaches to care, and teaming up with clinicians to deliver recommendations that are grounded in evidence but easy to act on. You’ll also have the chance to reimagine care protocols, helping us improve outcomes, elevate patient experiences, and celebrate every win against readmission. This is a remote opportunity— all candidates must reside within California and have a valid CA RN license.

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.