RN NURSE NAVIGATOR- TRANSITIONAL CARE & DISCHARGE COORDINATION

UHS•Laredo, TX

2d•Onsite

About The Position

The RN Nurse Navigator – Transitional Care & Discharge Coordination is a registered nurse responsible for proactively rounding on hospitalized patients to identify discharge needs, provide education, coordinate transition planning, and promote safe, timely discharges. The Nurse Navigator functions as a liaison between patients, families, physicians, nursing staff, case management, and community resources to improve continuity of care, reduce readmissions, and enhance the overall patient experience.

Requirements

Graduation from an accredited nursing education program required.
Current Registered Nurse (RN) license in the State of Texas required.
Strong communication and interpersonal skills with the ability to effectively interact with patients, families, physicians, and multidisciplinary teams.
Ability to prioritize, coordinate, and manage multiple patient needs in a fast-paced healthcare environment.
Ability to effectively communicate in English both verbally and in writing.
Proficient in electronic medical records and Microsoft Office applications.
BLS required.

Nice To Haves

Minimum of three (3) years of acute care nursing experience preferred.
Preferred experience in case management, discharge planning, utilization review, patient education, care coordination, or transitional care preferred.
Knowledge of community resources, discharge planning processes, and transitional care principles preferred.
Bilingual (English/Spanish) preferred.
ACLS preferred.

Responsibilities

Frequent patient rounding and direct interaction with patients and families throughout the hospitalization process to assess discharge readiness, identify barriers to discharge, and ensure a smooth transition of care.
Collaborate closely with physicians, nursing staff, case management, social services, therapy departments, and ancillary teams to coordinate discharge planning needs including follow-up appointments, home health services, durable medical equipment, transportation, medication access, and community resources.
Provides individualized patient and family education regarding diagnosis, medications, discharge instructions, disease management, follow-up care, and prevention of complications to support patient understanding and self-management after discharge.
Performs post-discharge follow-up telephone calls to assess patient status, reinforce discharge instructions, identify concerns or complications, ensure medication compliance, and confirm follow-up appointments were completed or scheduled appropriately.
Maintains accurate and timely documentation in the electronic medical record and participates in quality improvement initiatives focused on patient satisfaction, transitions of care, readmission reduction, and discharge efficiency.