NPST RN Care Coordinator

• Perform daily rounds to assess changes in Plan Members’ conditions, as well as obtain a daily Plan Member census evaluation, documenting and reporting to Plan NPs and RNPs which Plan Members were transferred out of the Facility (to the Emergency Department or for Hospitalization), who has elected Hospice Care, and who has returned from the Hospital in the past 24 hours.

• Partner with facility staff and other members of the Interdisciplinary Care Team (ICT) to implement care plans for Plan Members and identify and assist in the coordination of specialty or ancillary services, therapy, and/or other referral needs.

• Monitor Plan Members experiencing changes of condition, transitions to and from the hospital or other healthcare environment by working in coordination with facility staff to stay in touch with the hospital for updates and informing the Plan NP of the Plan Member’s hospitalized status. Ensure that the Plan Member’s discharge paperwork and summary are received by the Plan NP.

• Follow-up (in person) timely with each Plan Member after a transition to ensure that the Plan Member is not at risk for a readmission and to inform the Plan NP of any possible medical or other needs the Plan Member may have.

• Alert the Plan NP promptly of new enrollees and place urgency on the Plan NP’s intervention if the Plan Member is at risk for transition at any time.

• Perform all other duties congruent with the ISNP Plan as assigned.

Educational/Training Requirements

ADN, current Board Certification

Licensing Requirements

RN

Experience Requirements

The RNCC will comply with all State and Federal guidelines required to practice as a licensed Registered Nurse, including maintaining an active RN license in the state of Texas. The RNCC is responsible for maintaining ongoing Texas Board of Nursing educational requirements for licensure and re-certification.