Care Coordinator RN

Where You’ll Work

St. Joseph Health – Bryan/College Station, Navasota, Caldwell, Madisonville, TX. Since 1936, St. Joseph Health has been caring for the communities in and surrounding the Brazos Valley. We have a Level III Trauma Center, the first Joint Commission certified Primary Stroke Center, and the first accredited Chest Pain Center in the Brazos Valley. St. Joseph Health is a leader in critical care and the largest provider of cardiovascular care in the region. As an integrated healthcare system St. Joseph Health includes a comprehensive network of over 100 employed providers including primary care physicians specialists and advanced practice clinicians. The network includes more than 30 ambulatory clinics featuring primary care, Express Clinics, and imaging and diagnostic services.

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.

• Completes and documents a discharge planning assessment on those patients identified by the designated screening process, or upon request. Reassess the patient as appropriate and update the plan accordingly.
• Facilitates the development of a multidisciplinary discharge plan, engaging other relevant health team members, the patient and/or patient representative and post acute care providers in accordance with the patients clinical or psychosocial needs, choices and available resources.
• Oversees and evaluates the implementation of the discharge plan.
• Collaborates with the multidisciplinary team to ensure progression of care and appropriate utilization of inpatient resources using established evidence based guidelines/criteria.
• Collaborates with the healthcare team and post-acute service providers to ensure timely and smooth transitions to the most appropriate type and setting of post-acute services based upon patients clinical needs.
• Identifies risk for readmission and implements interventions to mitigate those risks for at least a 30-day period.

Job Requirements

Required

• Graduate of an accredited school of nursing and Minimum two (2) years of acute hospital clinical experience, upon hire or
• Masters Other Case Management or Nursing field. and 1 year of experience, upon hire and
• Registered Nurse: TX, upon hire and
• Basic Life Support - CPR, within 90 Days and

Preferred

• Bachelors Of Science Nursing and At least five (5) years of nursing experience., upon hire
• Certified Case Manager, upon hire and
• Accredited Case Manager, upon hire