Care Coordinator RN

CommonSpirit Health; College Park (TX); Presencial; USD 65.000 - 90.000; Jornada completa

Descripción de la vacante

St. Luke’s Health - The Woodlands Hospital is seeking an RN Care Coordinator to steer the patient care journey, coordinating discharge planning and post-acute transitions to ensure high-quality outcomes and patient experience.

You will collaborate with physicians, nursing, insurers, and post-acute providers, documenting assessments and advocating for patients with a strategic mindset to optimize care across all touchpoints.

Formación

• Graduate of an accredited nursing program with RN license in TX and acute hospital experience.
• Master's in Case Management or Nursing; 1 year of experience.
• CPR/BLS certification within 90 days of hire.

Responsabilidades

• Completes and documents discharge planning assessments and updates plans as needed.
• Develops a multidisciplinary discharge plan with the care team and post-acute providers.
• Oversees and evaluates the discharge plan implementation.
• Collaborates with the team to ensure progression of care and efficient use of inpatient resources.
• Coordinates timely transitions to appropriate post-acute services based on clinical needs.
• Identifies readmission risk and implements 30-day mitigation strategies.

Conocimientos

Discharge planning

Care coordination

Patient advocacy

Multidisciplinary collaboration

Communication

Educación

TX RN license

Master's in Case Management or Nursing

BSN preferred

Descripción del empleo

Job Summary and Responsibilities

As a RN Care Coordinator, you will be a central figure in patient care, seamlessly navigating the healthcare journey to achieve optimal outcomes and an exceptional patient experience.

Every day, you will strategically assess, plan, and facilitate comprehensive care across the continuum, expertly advocating for patients while collaborating with physicians, nursing, departments, insurers, and post-acute providers to ensure timely, high-quality transitions.

To be successful in this role, you will possess strong clinical acumen, exceptional communication and advocacy skills, and a strategic mindset, all driven by a passion for optimizing patient care across every touchpoint.

• Completes and documents a discharge planning assessment on those patients identified by the designated screening process, or upon request. Reassess the patient as appropriate and update the plan accordingly.
• Facilitates the development of a multidisciplinary discharge plan, engaging other relevant health team members, the patient and/or patient representative and post acute care providers in accordance with the patients clinical or psychosocial needs, choices and available resources.
• Oversees and evaluates the implementation of the discharge plan.
• Collaborates with the multidisciplinary team to ensure progression of care and appropriate utilization of inpatient resources using established evidence based guidelines/criteria.
• Collaborates with the healthcare team and post-acute service providers to ensure timely and smooth transitions to the most appropriate type and setting of post-acute services based upon patients clinical needs.
• Identifies risk for readmission and implements interventions to mitigate those risks for at least a 30-day period.

Job Requirements

• Graduate of an accredited school of nursing and Minimum two (2) years of acute hospital clinical experience, upon hire or
• Masters Other Case Management or Nursing field. and 1 year of experience, upon hire and
• Registered Nurse: TX, upon hire and
• Basic Life Support - CPR, within 90 Days and

Preferred

• Bachelors Of Science Nursing and At least five (5) years of nursing experience., upon hire
• Certified Case Manager, upon hire and
• Accredited Case Manager, upon hire

Where You'll Work

St. Luke’s Health - The Woodlands Hospital is a 245 bed facility serving North Harris and Montgomery counties. The hospital has been recognized as a Best Hospital by U.S. News & World Report, and is proud to serve as the clinical home for the Dan L Duncan Cancer Center. The hospital was awarded an “A” hospital safety grade by The Leapfrog Group in both 2023 and 2025. Clinical services provided include cardiovascular services, diagnostic imaging, women’s services (digital mammography and bone density studies), neurosciences, pediatric care (Newborn and Level III nurseries), surgery, pathology and pulmonary services, and sleep disorder services.