Overview St. Joseph Health - Bryan/College Station Navasota Caldwell Madisonville TX. Since 1936 St. Joseph Health has been caring for the communities in and surrounding the Brazos Valley. We have a Level III Trauma Center the first Joint Commission certified Primary Stroke Center and the first accredited Chest Pain Center in the Brazos Valley. St. Joseph Health is a leader in critical care and the largest provider of cardiovascular care in the region. As an integrated healthcare system St. Joseph Health includes a comprehensive network of over 100 employed providers including primary care physicians specialists and advanced practice clinicians. The network includes more than 30 ambulatory clinics featuring primary care Express Clinics and imaging and diagnostic services. Responsibilities ESSENTIAL KEY JOB RESPONSIBILITIES 1. Completes and documents a discharge planning assessment on those patients identified by the designated screening process, or upon request. Reassess the patient as appropriate and update the plan accordingly. 2. Facilitates the development of a multidisciplinary discharge plan, engaging other relevant health team members, the patient and/or patient representative and post-acute care providers in accordance with the patient's clinical or psychosocial needs, choices and available resources. 3. Oversees and evaluates the implementation of the discharge plan. 4. Collaborates with the multidisciplinary team to ensure progression of care and appropriate utilization of inpatient resources using established evidence based guidelines/criteria. 5. Collaborates with the healthcare team and post-acute service providers to ensure timely and smooth transitions to the most appropriate type and setting of post-acute services based upon patient's clinical needs. 6. Identifies risk for readmission and implements interventions to mitigate those risks for at least a 30-day period. 7. Responsible for delivery of appropriate patient notifications and related documentation 8. Responsible for patient education and advocacy. 9. Participates in performance improvement teams and programs as necessary. 10. Demonstrates behavior that aligns with the Mission and Core Values of the Organization. 11. Responsible for completing required education within established timeframes. 12. Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice. Qualifications Major Experience/Education: Minimum two (2) years of acute hospital clinical experience with ADN or a Master's degree in Case Management, or Master's Degree Nursing TX RN License Licensure/Certifications: Registered Nurse (RN) license