Care Coordinator RN

St Luke's Health - Memorial - Lufkin; Lufkin (TX); On-site; USD 70,000 - 90,000; Full time

Job summary

St. Luke's Health - Memorial Lufkin is seeking an RN Care Coordinator to navigate the patient care journey and optimize outcomes. You will plan and facilitate comprehensive care, advocate for patients, and collaborate with physicians, nursing, insurers, and post-acute providers to ensure timely, high-quality transitions.

The role requires strong clinical acumen, excellent communication, and a strategic mindset focused on improving patient care across touchpoints.

Qualifications

• Graduate of an accredited nursing program.
• Minimum two years of acute hospital clinical experience.
• RN licensed in Texas on hire.
• CPR/BLS within 90 days of hire.

Responsibilities

• Completes and documents a discharge planning assessment.
• Develops a multidisciplinary discharge plan with the patient, family, and post-acute providers.
• Oversees and evaluates the discharge plan implementation.
• Collaborates with the team to ensure appropriate inpatient resource use.
• Coordinates timely transitions to post-acute services based on clinical needs.
• Identifies readmission risks and implements mitigation strategies for at least 30 days.

Skills

Care coordination

Patient advocacy

Interdisciplinary collaboration

Communication

Clinical assessment

Education

RN license (TX)

Master's in Case Management or Nursing

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.