About Us Here at Baylor Scott & White Health we promote the well-being of all individuals, families, and communities. Baylor Scott and White is the largest not-for-profit healthcare system in Texas that empowers you to live well. Our Core Values are: We serve faithfully by doing what's right with a joyful heart. We never settle by constantly striving for better. We are in it together by supporting one another and those we serve. We make an impact by taking initiative and delivering exceptional experience. Benefits Our benefits are designed to help you live well no matter where you are on your journey. For full details on coverage and eligibility, visit the Baylor Scott & White Benefits Hub to explore our offerings, which may include: Immediate eligibility for health and welfare benefits 401(k) savings plan with dollar-for-dollar match up to 5% Tuition Reimbursement PTO accrual beginning Day 1 Note: Benefits may vary based upon position type and/or level. Job Summary You'll oversee patient care, using guidelines to establish benefits and resolve service necessity issues. Various roles will be adopted to encourage optimal outcomes. Manage care efficiently to reduce unnecessary usage. Essential Functions of the Role Producing, implementing, documenting, and updating care plans in collaboration with the entire healthcare team Formulating patient care management plans and setting treatment and self-management goals. Evaluating the healthcare, educational, and psychosocial requirements of the patient and their family. Helping patients stay healthy by educating, visiting, and communicating via phone; also, supporting adherence to care plans. Studying, establishing, and recommending resources to fulfill medical and non-medical needs of patients and families. Collaborating with all programs to ensure proper coordination of services. Proactively identifying issues and suggesting solutions for care coordination to ensure it's in the best setting. Communicating and linking with hospital, long-term care, and home health representatives. Key Success Factors Completion of an associate degree in nursing. Completion of a specialty certification is highly recommended. Familiarity with care coordination, managing resources and handling patient needs effectively. Proficiency in assessing patient health and creating effective management plans accordingly. Outstanding verbal and written communication skills. Ability to diligently monitor, evaluate and document patient progress in line with a care plan. Capability to aid patient access to community resources. Willingness to collaborate with both in-house and external medical professionals, partner agencies and organizations. Ability to handle rapidly changing situations and potential crises with understanding and composure. Commitment to ensuring confidentiality of patient details in line with all relevant policies and regulations. Belonging Statement We believe that all people should feel welcomed, valued and supported. Qualifications Associate's degree (2) two years of hands-on experience in the relevant field. An (RN) Registered Nurse license is required.
