RN Care Navigator: Seamless Discharge & Care Transitions

CommonSpirit Health; Lufkin (TX); On-site; USD 51,000 - 76,000; Full time

Job summary

CommonSpirit Health seeks an RN Care Coordinator to support seamless patient transitions and optimize outcomes in a hospital setting. You will assess, plan, and facilitate comprehensive care across the continuum, collaborating with physicians, nursing, insurers, and post-acute providers to ensure timely, high-quality transitions.

You will advocate for patients with strong clinical acumen and communication skills, driving coordinated care and discharge planning across the care team to improve

Qualifications

• Graduate of an accredited school of nursing.
• Minimum two (2) years of acute hospital clinical experience.
• Current RN license in TX at time of hire.
• BLS CPR certification within 90 days of hire.

Responsibilities

• Completes and documents discharge planning assessments as identified, updates plan as needed.
• Facilitates multidisciplinary discharge planning with patient, family and post-acute providers.
• Oversees and evaluates discharge plan implementation.
• Collaborates with care teams to ensure appropriate inpatient resource use and transitions.
• Coordinates with post-acute providers for timely transitions based on clinical needs.
• Identifies readmission risk and implements 30-day mitigation strategies.

Skills

Discharge planning

Care coordination

Interdisciplinary collaboration

Readmission risk assessment

Advocacy and communication

Education

Master's in Case Management or Nursing

Bachelor of Science in Nursing

Tools

CPR

Job description

CommonSpirit Health seeks an RN Care Coordinator to support seamless patient transitions and optimize outcomes in a hospital setting. You will assess, plan, and facilitate comprehensive care across the continuum, collaborating with physicians, nursing, insurers, and post-acute providers to ensure timely, high-quality transitions.

You will advocate for patients with strong clinical acumen and communication skills, driving coordinated care and discharge planning across the care team to improve