RN Care Coordinator: Discharge & Care Transitions Lead

CHI; Caldwell (TX); On-site; USD 106,651,000 - 158,658,000; Full time

Job summary

St. Luke’s Health – Memorial Lufkin is seeking a RN Care Coordinator to lead discharge planning and care coordination across the hospital stay. You will assess patient needs, develop discharge plans with a multidisciplinary team, and ensure safe transitions to post-acute care settings.

The role requires an RN with Texas licensure, at least two years of acute hospital experience, and CPR certification within 90 days of hire. Strong communication and advocacy skills are essential.

Qualifications

• Graduate of an accredited school of nursing.
• Minimum two (2) years of acute hospital clinical experience.
• RN license in Texas at hire.
• Basic Life Support (CPR) required within 90 days.

Responsibilities

• Completes and documents discharge planning assessments.
• Facilitates multidisciplinary discharge planning with patients, families, and post-acute providers.
• Oversees and evaluates discharge plan implementation.
• Collaborates with care teams to ensure progression of care and 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

CPR

Education

RN license (TX)

Master's in Case Management or Nursing

BSN (preferred)

Job description

St. Luke’s Health – Memorial Lufkin is seeking a RN Care Coordinator to lead discharge planning and care coordination across the hospital stay. You will assess patient needs, develop discharge plans with a multidisciplinary team, and ensure safe transitions to post-acute care settings.

The role requires an RN with Texas licensure, at least two years of acute hospital experience, and CPR certification within 90 days of hire. Strong communication and advocacy skills are essential.