Care Coordinator RN

CommonSpirit Health; Lufkin (TX); On-site; USD 65,000 - 90,000; Full time

Job summary

St. Luke's Health - Memorial Lufkin is seeking a RN Care Coordinator to centralize patient care, guiding the healthcare journey to optimize outcomes and patient experience.

The role requires coordinating discharge plans, collaborating with physicians, nursing, insurers, and post-acute providers to ensure timely, high-quality transitions. Candidates should demonstrate strong clinical acumen and exceptional communication and advocacy skills, with a strategic mindset focused on optimizing care

Qualifications

• Strong clinical acumen and advocacy skills.
• Experience in discharge planning and care coordination.
• Ability to collaborate with multidisciplinary teams.

Responsibilities

• Complete and document discharge planning assessments and update plans.
• Develop multidisciplinary discharge plans with patients, families, and post-acute providers.
• Oversee implementation of discharge plans and ensure progress of care.
• Collaborate with healthcare team to optimize inpatient resource use per guidelines.
• Ensure timely transitions to appropriate post-acute services.
• Identify readmission risk and implement 30-day mitigation interventions.

Skills

Communication skills

Advocacy

Discharge planning

Care coordination

Education

Masters in Case Management or Nursing

Registered Nurse (TX)

Job description

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

Required

• 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 - Memorial Lufkin is a 279 bed facility and member of CommonSpirit Health, a national nonprofit health system. Serving East Texas, St. Luke's Health-Memorial Lufkin provides more than a quarter of a million patient services annually and contributes millions of dollars in local charity care and community support. We’re the area’s first Joint Commission Certified Primary Stroke Center, with board-certified neurologists and neurosurgeons offering full-spectrum stroke care. Nationally recognized as a HealthCare Center of Excellence, St. Luke's Health-Memorial Lufkin offers compassionate, comprehensive health care, including off-campus rehab and outpatient facilities and services. In addition to its large emergency department, there are 32 private rooms, dedicated imaging and OBGYN, wound care, infusion and lab services.