Nurse Care Coordinator

Employees in this classification are registered nurses responsible for helping manage a patient's care by coordinating the patient's treatment plans, educating them about their condition, connecting them with health care providers, and evaluating their progress. The incumbent will be responsible for consulting with patients, family members, and the health care team to determine patient needs, develop care plans, coordinate patient services, develop expected patient outcomes, and work with the care team to evaluate interventions. Requires a high degree of contact with patients, families, and TTUHSC clinic staff. 

A Transitional care management (TCM) nurse coordinates a patient's care as they move between healthcare settings, such as from hospital to home, to prevent complications, hospital readmissions, and improve health outcomes. The overall goal is to ensure a seamless transition, enhance the continuity of care, and empower patients to manage their health effectively.

• Identifying high-risk patients.
• Conducting post-discharge follow-up calls and visits within specific timeframes and using clinic protocols.
• Reconciles the discharge medication list.
• Provides education to patients and caregivers, along with implementing teaching plans for patients and their families with health learning needs.
• Promotes and reinforces patient-centered medical home concepts with patients, their family, and clinic personnel.
• Works proactively to prevent complications, reduce hospital readmissions, and manage patient populations by identifying and addressing quality gaps in care needs.
• Audits charts utilizing custom report data, identifies and reports alterations in patient responses to assist in the identification of problems and formulation of goals/ outcomes and patient-centered plans of care in collaboration with patients, their families, and the interdisciplinary health care team.
• Assists in determining the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families.
• Communicates patient data using EMR to support decision-making to improve patient care.
• Participates in the identification of patient needs for referral to resources and facilitates continuity of care.
• Completes Annual Nursing Core Competency Training and maintains current nurse licensure. 
   

Graduated from an approved, accredited nursing program. A minimum of 2 years of experience in a clinical or community resource setting; Care coordination and/or case management experience is desirable. Current RN license in the State of Texas or ability to attain a temporary permit from the Board of Nursing to practice nursing pending full licensure in the state of Texas.