Transition Care Coordinator-Licensed

St. Joseph Health Grimes Hospital is a 25- bed critical access hospital in Navasota, Texas offering a Level IV Trauma Center, in-patient and out-patient services, physical therapy, emergency care, occupational therapy, skilled nursing care, injury treatment and more. 

The ED includes a triage room, 5 patient rooms and a central nurses' station. The ED maintains a specific designation for Stroke and Trauma care and is equipped with 24-hour emergency services, laboratory, and CT scans.

As a Transition Care Coordinator, you will provide critical support and meticulous coordination for patients transitioning between care settings, ensuring a safe, seamless, and well-planned continuum of care.

Every day you will expertly assess patient needs for discharge, arrange post-acute services, educate patients and families, and meticulously collaborate with multidisciplinary teams to ensure comprehensive and individualized transition plans.

To be successful, you will demonstrate outstanding organizational skills, strong communication abilities, and an empathetic, proactive demeanor, contributing significantly to reduced readmissions and improved patient outcomes post-transition.

• Admission Growth- Identify patients appropriate for Critical Access Hospital admission, observation, swing bed, outpatient services, and other hospital programs. Collaborate with physicians and clinical staff to maximize appropriate admissions. Review Emergency Department transfers for opportunities to retain patients locally. Promote utilization of inpatient, observation, swing bed, rehabilitation, infusion, imaging, laboratory, wound care, and specialty services.
• Transition of Care- Coordinate safe and efficient transitions from the Emergency Department, physician offices, other hospitals, skilled nursing facilities, and home. Serve as liaison between patients, families, providers, and community partners. Support initiatives that reduce avoidable readmissions and improve patient outcomes.
• Outmigration Reduction- Review transfer requests and referral patterns to identify opportunities to keep care local. Track reasons for patient outmigration and recommend process improvements. Identify barriers to admission and work with leadership to implement solutions.
• Community & Physician Relations- Develop relationships with EMS, physician practices, clinics, long-term care facilities, home health agencies, and community organizations. Educate referral sources regarding services available at St. Joseph Health Grimes Hospital. Participate in outreach activities to increase awareness and utilization.
• Operational Excellence- Participate in daily interdisciplinary huddles and throughput meetings. Monitor admission, transfer, swing bed, readmission, and transition metrics. Provide leadership with reports identifying growth opportunities.

Required

• Associates Degree or above in Nursing, Healthcare Admin, Social Work, Therapy, Public Health, Health Sciences, Business, or another healthcare related field upon hire
• One years healthcare experience.
• One of the following upon hire: Registered Nurse: TX (RN:TX), Occupational Therapist: TX (OT:TX), Physical Therapist: TX (PT:TX), Licensed Clinical Social Worker: TX

   

Preferred

• Experience in care coordination, admissions, therapy, case management, discharge planning, physician relations, business development, rural healthcare, or patient navigation.
• Critical Access Hospital experience.