RN Care Coordinator: Discharge Planning & Transitions

St. Luke's Hospital - The Woodlands; The Woodlands (TX); On-site; USD 59,000 - 88,000; Full time

Job summary

St. Luke’s Health - The Woodlands Hospital is seeking a RN Care Coordinator to orchestrate patient care across the continuum, advocating for patients and collaborating with physicians, nursing, and post-acute providers to ensure high-quality transitions.

You will assess, plan, and facilitate comprehensive care, aiming for optimal outcomes and exceptional patient experience, with emphasis on reducing readmission risks and coordinating across multiple teams.

Qualifications

• Graduate of an accredited school of nursing with at least 2 years of acute hospital clinical experience.
• Masters in Case Management or Nursing field, with 1 year of experience at hire.
• Registered Nurse license in TX; Basic Life Support (CPR) within 90 days of hire.
• Preferred: BSN and at least 5 years of nursing experience.
• Preferred: Certified Case Manager.
• Preferred: Accredited Case Manager.

Responsibilities

• Completes and documents a discharge planning assessment for identified patients and reassesses as needed.
• Develops a multidisciplinary discharge plan with the health team, patient, and post-acute providers.
• Oversees and evaluates the discharge plan implementation.
• Collaborates with the team to ensure care progression and appropriate inpatient resource use.
• Coordinates with post-acute services for timely transitions based on clinical needs.
• Identifies readmission risk and implements 30-day mitigation interventions.

Skills

Acute hospital clinical experience

Care coordination

Discharge planning

CPR/BLS certification

Education

RN license (TX)

Masters in Case Management or Nursing

Bachelor's Degree in Nursing (BSN)

Job description

St. Luke’s Health - The Woodlands Hospital is seeking a RN Care Coordinator to orchestrate patient care across the continuum, advocating for patients and collaborating with physicians, nursing, and post-acute providers to ensure high-quality transitions.

You will assess, plan, and facilitate comprehensive care, aiming for optimal outcomes and exceptional patient experience, with emphasis on reducing readmission risks and coordinating across multiple teams.