**Overview** St. Luke’s Health is the largest Catholic health system in greater Houston and southeast Texas. Our integrated delivery network comprises sixteen hospitals covering Houston, Brazos Valley, southeast Texas and Lake Jackson, and East Texas and Lufkin, and includes Baylor St. Luke’s Medical Center, the research and teaching hospital for Baylor College of Medicine. St. Luke’s Health is home to the Texas Heart ®Institute (THI), the top ranked heart center in Houston, and the Dan L Duncan Comprehensive Cancer Center, a nationally ranked NCI designated cancer center. Our integrated network of care includes more than 398 employed and 1,668 clinically aligned network providers, and more than 20,000 employees delivering high value, nationally ranked quality and compassionate care along with our Christian ministry of healing. Our goal is to deliver accessible, nationally recognized high quality care through the highest value network for choice in healthcare for patients, employers and payers with a commitment to an equitable and personalized patient experience for all consistent with our ministry of healing. **Responsibilities** With guidance from the local market leadership, the RN Continuing Care Coordinator works collaboratively with physicians, staff and other health care professionals within his/her clinically setting to maintain and improve quality and sustainability within the local market network, this work includes: + Chronic Disease Management—Develops a plan of care based on a nursing assessment of the patient and their individual circumstances. The plan of care will include patient and caregiver education as well as coordination and collaboration of care with an interdisciplinary team working with that patient. The RN will also be responsible for monitoring the patient’s progress with the care plan. + Practice Pattern Management—Referral Management, based upon local program criteria. + Performance Data Interpretation—Participates in development of workflows and audits. + Evidence-Based Metric (EBM) guidelines / care plans—Implements and hardwires different EBM guidelines in the ambulatory setting as well as facilitating seamless transitions of care between clinic and post-acute settings and between clinic and other health professionals. **ESSENTIAL KEY JOB RESPONSIBILITIES** Assessment + Works with “at risk” patients and families on self-management support. + Anticipates and identifies variances in the care process related to those identified needs. Modifies plan of care to resolve unexpected care needs. Leadership + Leads an interdisciplinary healthcare team in the management of high risk patients referred to the Continuing Care program, facilitating collaboration, communication and coordination among all responsible parties of the multidisciplinary healthcare team striving to eliminate fragmentation, duplication or gaps in care. + Designs plans for data gathering and analysis of baseline, and ongoing assessment of success throughout the project; provides ongoing support to practitioners in collecting, interpreting, and communication data, and developing action plans accordingly. Works toward reduction of preventable hospital admissions, re-admissions, excessive therapies, DME, etc. Critical Thinking + Assists patients and or caregiver with navigating the healthcare system to minimize fragmentation in services, obtain timely care and appropriate access to providers, services and necessary procedures anticipating barriers to care when possible. + Monitors members compliance with scheduling and keeping PCP and specialist appointments identifying patterns of nonadherence and coordinates scheduling of needed member appointments. + Reports to the Care Coordination Manager or Director for Quality and Utilization regarding member status and identifies any potential risk management. Relationships + Leads efforts to optimize care coordination across the care continuum, building and maintaining positive relationships with the healthcare team. + Assumes responsibility, authority and accountability for patient load, assisting other coworkers when requested or as the need arises. + Uses appropriate resources and methods to resolve conflicts with others in a positive and professional manner. **May also be required to meet patients and or family members either in the community, at home, or other location.** Must be able to assess the environment for safety for self and patients and escalate any concerns to the Medical Social Worker, Licensed Social Worker or program manager based on the situation. **REMOTE - PREFERRED CANDIDATE TO BE LOCATED IN THE HOUSTON, TX AREA.** **Qualifications** **Required Education and Experience:** + Associate degree in Nursing required + Two (2) years relevant experience or advanced degree required _Preferred: Bachelor Science degree in Nursing (BSN)_ _Preferred: Three-Five (3-5) years_ **Required Licensure and Certifications:** + Texas RN **Required Minimum Knowledge, Skills, Abilities and Training:** + Manages and works closely with interdisciplinary partners in the management of identified patient populations. Oversees a mix of clinical, operational, and business activities related to that team. + Implements specific program goals including high priority case management redesign efforts required to improve performance. + Works closely with and in partnership with Community resource partners, Post Acute Care Providers, Acute Care Coordinators and other clinical staff who are focused on care coordination in order to ensure that patients' care and transition of care from acute care to post-acute and ambulatory care are seamless. + Assesses, reports, and communicates patient status on a periodic basis to all team stakeholders. + Excellent computer skills and ability to learn new systems. + Strong organizational (time management) and interpersonal skills. + Ability to handle multiple priorities with strong attention to detail. + Ability to communicate effectively using written and verbal skills. Proficient in email communications and internet usage along with basic use of Google Suites. + Knowledge of information technology to evaluate care effectiveness (care process, outcomes and cost). + Ability to work autonomously within a matrix environment without direct supervision or support. **_DISCLOSURE SUMMARY_** _The job summary and responsibilities listed above are designed to indicate the general nature of the work performed within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities required of employees assigned to this job. Employees may be required to perform other duties as assigned._ **Pay Range** $36.96 - $53.60 /hour We are an equal opportunity/affirmative action employer.