Patient Care Services Liaison Registered Nurse

Star Care Specialty Health System (Star Care) is seeking a full-time Patient Care Services Liaison Registered Nurse to join its outstanding Aging & Disability team. The Patient Care Services Liaison is a Registered Nurse (RN) responsible for coordinating and supporting comprehensive, participant-centered healthcare services through collaboration with the Medical Director, healthcare providers, clinic staff, RN Case Managers, participants, and families. This role provides clinical support within the Adult Day Activity Center, including participant assessment, triage, medication administration, oversight of approved self-medication programs, and health education.

The position also supports care transitions through hospital and facility visits, discharge planning, durable medical equipment (DME) coordination, and arrangement of home and community-based services. Additional responsibilities include conducting nursing assessments, maintaining accurate clinical documentation, participating as an active member of the Interdisciplinary Team (IDT), performing home and facility visits as needed, and ensuring compliance with all applicable nursing standards, regulatory requirements, and organizational policies.

The role also participates in on-call coverage and supports special projects and assignments as needed to promote quality care and positive participant outcomes.

Responsibilities:

• Collaborate with healthcare providers, clinic nursing staff, and RN Case Managers to coordinate and support high-quality, participant-centered healthcare services.
• Provide onsite clinical support within the Adult Day Activity Center, including participant assessment, triage, monitoring of health concerns, and timely intervention as needed.
• Oversee approved self-medication programs and administer prescribed medications in accordance with provider orders, agency policies, and regulatory requirements.
• Support medication management through ongoing collaboration with participants, families, caregivers, and healthcare providers.
• Conduct hospital and facility visits to facilitate care coordination, monitor participant status, and support continuity of care.
• Coordinate hospital follow-up, discharge planning, durable medical equipment (DME), and home and community-based services to ensure successful care transitions.
• Assist with conducting semi-annual nursing assessments and other clinical evaluations as needed.
• Provide participant and family education to promote health, wellness, self-management, and positive health outcomes.
• Participate as an active member of the Interdisciplinary Team (IDT) to develop, implement, and monitor comprehensive person-centered care plans.
• Maintain accurate, timely, and compliant clinical documentation, including nursing assessments, progress notes, care plans, and other required records.
• Perform home and facility visits as necessary to assess participant needs and support service delivery.
• Ensure compliance with Texas Board of Nursing standards, organizational policies, PACE regulations, and applicable healthcare regulations.
• Assist supervisors and center staff with special projects, quality improvement initiatives, and other assigned responsibilities.
• Participate in the on-call rotation, including periodic weekend coverage, to ensure ongoing participant support and continuity of care.
• Maintain regular and consistent attendance for the assigned work hours.
• Ensure all required training and credentials are current and compliant with Center, federal, state, and local regulations, in addition to Star Care policies and procedures.
• Complete special departmental projects and other responsibilities with similar skill and work conditions as assigned.
• Support all activities in alignment with Star Care’s mission,…