Continuing Care Coordinator RN

Reid Home Health; Houston (TX); Hybrid; USD 70,000 - 95,000; Full time

Job summary

Baylor St. Luke’s Medical Center seeks an RN Care Coordinator to navigate patient care across the continuum, advocating for patients and coordinating with physicians, nursing, insurers and post-acute providers.

The role emphasizes clinical nursing expertise, strong communication, and strategic planning to improve outcomes and care transitions in a hospital setting.

Qualifications

• Must have Associate of Arts in Nursing and 2 years relevant experience or an advanced degree.
• Licensed registered nurse in Texas (TX) upon hire.
• Preferred BSN with 3–5 years of experience.

Responsibilities

• Assess at-risk patients, design care plans, document, implement and evaluate outcomes.
• Coordinate care across provider sites and interdisciplinary teams.
• Lead an interdisciplinary healthcare team to minimize fragmentation in care.
• Assist patients and caregivers navigating the healthcare system for timely access.
• Monitor scheduling adherence and coordinate PCP and specialist appointments.

Skills

Clinical acumen

Communication

Advocacy

Education

Associate of Arts in Nursing

Registered Nurse (TX)

Bachelor of Science in 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.

• Assessment

  Works with “at risk” patients and families on self-management support including:

  Performing individual needs assessment, care plan design, education, documentation, implementation, and evaluation of outcomes according to state and national guidelines, policies, procedures, and protocols as required.

  Following evidence-based care pathways

  Coordinating care across multiple provider sites and interdisciplinary teams

  Working with patients to create a plan of care for health behavior change:

  Assessing and working on the patient’s readiness to change, the importance of change, and confidence in ability to change

  Helping the patient to identify and overcome barriers

  Setting short and long-term goals for self-management of chronic disease, empowering the patient, family and /or caregiver to achieve maximum levels of wellness and independence.

  Referring to appropriate services when applicable including but not limited to community resources and services to address the established goals or desired outcomes.

  Anticipates and identifies variances in the care process related to those identified needs. Modifies plan of care to resolve unexpected care needs.

• Leadership

  Leads an interdisciplinary healthcare team in the management of high risk patients referred to the Continuing Care program, facilitating collaboration, communication and coordination among all responsible parties of the multidisciplinary healthcare team striving to eliminate fragmentation, duplication or gaps in care.

  Designs plans for data gathering and analysis of baseline, and ongoing assessment of success throughout the project; provides ongoing support to practitioners in collecting, interpreting, and communication data, and developing action plans accordingly. Works toward reduction of preventable hospital admissions, re-admissions, excessive therapies, DME, etc.

  Critical Thinking

• Assists patients and or caregiver with navigating the healthcare system to minimize fragmentation in services, obtain timely care and appropriate access to providers, services and necessary procedures anticipating barriers to care when possible.

• Monitors member's compliance with scheduling and keeping PCP and specialist appointments identifying patterns of nonadherence and coordinates scheduling of needed member appointments

• Reports to the Care Coordination Manager or Director for Quality and Utilization regarding member status and identifies any potential risk management.

Relationships

• Leads efforts to optimize care coordination across the care continuum, building and maintaining positive relationships with the healthcare team.
• Assumes responsibility, authority and accountability for patient load, assisting other coworkers when requested or as the need arises.
• Uses appropriate resources and methods to resolve conflicts with others in a positive and professional manner.
• May also be required to meet patients and or family members either in the community, at home, or other location. Must be able to assess the environment for safety for self and patients and elevate any concerns to the Medical Social Worker, Licensed Social Worker or program manager based on the situation.
• May also be required to:
• Concerns or complaints
• Research and recommend appropriate follow-up and or corrective measures
• Identify opportunities to achieve department process excellence through a thorough analysis of available data and involvement of interdisciplinary teams
• Department Audits
• Assist with audits at the direction of the manager
• Consolidate audit results and provide analysis of results
• Day to day operations:
• At the direction of the manager, assist with hiring by organizing peer interviews
• Work in conjunction with management to ensure daily performance of staff supports effective, safe and efficient patient care and department operations
• Mentor new employees meeting weekly with the employee and or leadership to track progress, ensure appropriate communication with team members
• Identifies and actively participates (or leads) projects to assist with team self-actualization
• Designs plans for data gathering and analysis of baseline, and ongoing assessment of success throughout the project, provides ongoing support to team members in collecting, interpreting, and communication of data, and developing action plans accordingly.
• Team conferences
• Attend and participate at interdisciplinary team meetings
• Initiate patient care conferences when needed.
• Committee participation outside of operational departmental work

Job Requirements

Required

• Associate Of Arts Nursing and 2 years relevant experience or advanced degree, upon hire and
• Registered Nurse: TX, upon hire

Preferred

• Bachelors Of Science Nursing and 3 to 5 years, upon hire

Where You'll Work

Baylor St. Luke’s Medical Center is an 881-bed quaternary care academic medical center that is a joint venture between Baylor College of Medicine and CHI St. Luke’s Health. Located in the Texas Medical Center, the hospital is the home of the Texas Heart® Institute, a cardiovascular research and education institution founded in 1962 by Denton A. Cooley, MD. The hospital was the first facility in Texas and the Southwest designated a Magnet® hospital for Nursing Excellence by the American Nurses Credentialing Center, receiving the award five consecutive times. Baylor St. Luke’s also has three community emergency centers offering adult and pediatric care for the Greater Houston area.