RN Care Coordinator

Description

Facilitates patient progression across the continuum of care, from pre-admission through discharge, ensuring timely and coordinated transitions. Develops comprehensive discharge plans tailored to individual patient needs, promoting safe and effective continuity of care.

Evaluates patients to identify discharge planning needs and directs care accordingly to ensure safe and effective transitions. Serves as a patient advocate, assisting in the resolution of concerns and barriers to care. Conducts comprehensive assessments of new patients to determine physical, mental, and emotional health needs, and collaborates with the care team to establish appropriate treatment plans.

Collaborates with the interdisciplinary care team and external facilities to ensure effective discharge planning and continuity of care. Facilitates communication among patients, families, and service providers to coordinate care and support patient-centered outcomes.

Promotes high-quality, cost-effective care by identifying appropriate interventions and facilitating outcomes that align with clinical best practices and resource stewardship.

Monitors resource utilization to ensure the most effective and efficient use of services.

Identifies patient education needs and psychosocial factors that may impact care outcomes, and addresses them to support optimal recovery and well-being. Advocates for patients by helping them navigate complex healthcare and social service systems, ensuring timely access to necessary resources and services.

Assists in aggregating data to support quality improvement and trend analysis. Maintains accurate and up-to-date case documentation, including case notes, care plans, and other relevant information to ensure continuity and compliance.

Ensures compliance with established best practices and regulatory requirements, including CIHQ, CMS Conditions of Participation, and applicable state laws governing medical necessity and case management. Maintains adherence to recognized Case Management Standards to support safe, effective, and legally compliant patient care.

Identifies and addresses social determinants of health that may impact patient outcomes, including barriers related to mental health, housing, transportation, and access to care. Responds appropriately to psychosocial risk factors, such as self-harm concerns, by initiating safety protocols and coordinating referrals to behavioral health professionals and community resources to ensure patient safety and continuity of care.

Other duties and projects as assigned.

This position requires weekend call of approximately two weekends per month.

The RN Care Coordinator plays a critical role in assessing patient needs, developing individualized care plans, and facilitating access to appropriate healthcare and social services for Texas Institute for Surgery (TIS) patients. This position serves as a patient advocate, working collaboratively with patients, families, and interdisciplinary providers to navigate complex healthcare systems and ensure continuity of care throughout the surgical episode.

Key responsibilities include conducting comprehensive patient assessments, coordinating treatment plans, maintaining accurate and detailed documentation, and promoting cost-effective, high-quality care. The RN Care Coordinator also identifies and recommends alternative care options for patients transitioning from inpatient surgical settings or requiring long-term support, ensuring that care delivery aligns with both clinical needs and patient preferences.

Job Qualifications

Education & Training:

Licenses / Certifications:

Associate Degree in Nursing, BSN preferred.

Current Texas RN license required

Current BLS, required.

Commission for Case Manager Certification (CCMC), preferred.

Experience:

Key Skills:

Previous experience in care/case management required.

Familiarity with MCG (Milliman Care Guidelines) preferred, including the ability to apply evidence-based criteria to support clinical decision-making, utilization review, and discharge planning.

Experience in regulatory requirements, including CIHQ and CMS.

Able to problem solve and use critical thinking.

Excellent Customer Service skills required.