Care Transitions Nurse Educator – RN Full Time


Full Time:  Day Shift


Coryell Health

Job Description:

Summary: Performs assigned nursing/social services duties, including assessing, planning, implementing, and evaluating patient care. Also performs a wide variety of patient care activities including, but not limited to, maintenance of clinical record/documentation, discharge planning, referrals, service linkage, patient education, follow up with patients post hospitalization, and coordination of patient care post hospitalization. Tends to the day to day issues and communicates needs and issues with patient, patient’s family as appropriate, and other staff. Actively participates in outstanding customer service and accepts the responsibility in maintaining relationships that are equally respectful to all.


Job Qualifications:


1. State of Texas Registered Nurse license (RN)
2. Basic Life Support certification
3. Maintain updated competencies and CEUs
4. Two years or more of medical experience with a least one year in the ambulatory care setting
5. Good physical and mental health
6. Ability to work under pressure
7. Acute sense of responsibility, loyalty and dedication
8. Good oral and written communication skills.
9. Excellent customer service skills.

1. Provide education to patients about new and chronic diagnoses.
2. Provide patient education about new medications.
3. Medication reconciliation as necessary for patient education.
4. Meet with patients upon admission and communicate with them throughout their hospitalization regarding their medical conditions. Provide education on new diagnoses, continuing diagnoses and medications. Document patient response in the medical record.
5. Support the Care Transitions Social Worker with coordination of discharge planning needs with patients and families.
6. Provide support to the Care Transitions Social Worker regarding Extended Care admissions to include receiving referrals from other facilities.
7. Provide support to Care Transitions Social Worker for EC admission paperwork to verify patient understanding.
8. communicate with all patients as per requirements of post hospitalization follow-up schedule to verify compliance with follow-up appointments, medications, and service linkage.
9. Attend daily Huddle meetings
10. Support the Care Transitions Social Worker in coordinating weekly Discharge Planning meetings.
11. Make referrals to the Accountable Care Coordination program when appropriate.
12. Email primary care providers when one of their patients is admitted to the hospital.
13. Basic understanding of rules, regulations, and retrieval of insurance information
14. Coordinate with other disciplines as necessary
15. Keeps up to date on current standards for infection control practices, safety procedures (TDH, OSHA, JCAHO, DFA, and CMS), technical procedure manuals and operational protocols.
16. And all other duties as assigned.

How to Apply

Thank you for looking at our facility as a possible place for your future career path.
In addition to your resume, we also need an application completed with our organization.

From our job posting click on PDF Application.
Please download an application. Save this to your desktop with a different file name. Then when you open that file you can use the Fill & Sign features.
Complete the application using Adobe or print it out and fill it all in as much as possible.
Make sure you give us (3) Three Personal References not related to you and phone numbers.
We will need contact information from your Previous Employers or supervisor and phone numbers.
Please fax the application to us if you can’t save as a separate PDF to attach to an e-mail for us.
We look forward to hearing from you soon!

Download PDF Application