RN Care Coordinator: Lead Seamless Patient Transitions

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

Job summary

St. Luke’s Health - The Woodlands Hospital is seeking an RN Care Coordinator to steer the patient care journey, coordinating discharge planning and post-acute transitions to ensure high-quality outcomes and patient experience.

You will collaborate with physicians, nursing, insurers, and post-acute providers, documenting assessments and advocating for patients with a strategic mindset to optimize care across all touchpoints.

Qualifications

• Graduate of an accredited nursing program with RN license in TX and acute hospital experience.
• Master's in Case Management or Nursing; 1 year of experience.
• CPR/BLS certification within 90 days of hire.

Responsibilities

• Completes and documents discharge planning assessments and updates plans as needed.
• Develops a multidisciplinary discharge plan with the care team and post-acute providers.
• Oversees and evaluates the discharge plan implementation.
• Collaborates with the team to ensure progression of care and efficient use of inpatient resources.
• Coordinates timely transitions to appropriate post-acute services based on clinical needs.
• Identifies readmission risk and implements 30-day mitigation strategies.

Skills

Discharge planning

Care coordination

Patient advocacy

Multidisciplinary collaboration

Communication

Education

TX RN license

Master's in Case Management or Nursing

BSN preferred

Job description

St. Luke’s Health - The Woodlands Hospital is seeking an RN Care Coordinator to steer the patient care journey, coordinating discharge planning and post-acute transitions to ensure high-quality outcomes and patient experience.

You will collaborate with physicians, nursing, insurers, and post-acute providers, documenting assessments and advocating for patients with a strategic mindset to optimize care across all touchpoints.