Care Coordinator RN

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

Job summary

CommonSpirit Health's Lakeside Hospital in The Woodlands, TX seeks an RN Care Coordinator to guide patients through the healthcare journey from admission to post-acute care. You will advocate for patients, collaborate with physicians, nursing staff, insurers, and post-acute providers to ensure timely, high-quality transitions and optimal outcomes.

The role requires a registered nurse with acute hospital experience, BLS/CPR, and a strong focus on patient advocacy and care optimization across

Qualifications

• Graduate of an accredited school of nursing and minimum two (2) years of acute hospital clinical experience.
• Registered Nurse: TX license required.
• Basic Life Support (BLS/CPR) certification within 90 days of hire.

Responsibilities

• Completes and documents discharge planning assessments for patients identified by screening or on request.
• Develops and monitors multidisciplinary discharge plans with patients, families, and post-acute providers.
• Oversees implementation of the discharge plan and ensures timely transitions.
• Collaborates with the care team to ensure appropriate inpatient resource use per guidelines.
• Identifies readmission risk and implements mitigation strategies for at least 30 days.

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–Lakeside Hospital in The Woodlands is a 30 bed facility dedicated to enhancing your health and well-being. Our facility is a collaboration between St. Luke’s Health and a team of specialized physicians—focused on general and interventional cardiology, sports medicine, and orthopedics, including total joint replacement and spine care—in the North Houston community. As the only hospital in Montgomery County to offer sports medicine as a major service line, Lakeside Hospital provides inpatient and outpatient care as well as diagnostic imaging, including MRI, CT, and nuclear medicine. St. Luke’s Health is a member of CommonSpirit.