Licensed Vocational Nurse (LVN) FT - Days - Nurse Navigator - Transitional Care Management (Carelink)

Nursing (RN and LVN) Edinburg, Texas


Position at DHR Health


Responsible for follow up communication and coordination for continuum of care.  Responsible for addressing any barriers and will communicate with department directors and physicians as required.



  • License Vocational Nurse (L.V.N.)
  • Current Texas licensure
  • Minimum of two year of clinical or related hospital experience
  • Ability to communicate clearly and concisely with all levels of nursing, administration, and physicians
  • Demonstrated leadership experience
  • Ability to read, write and speak English required
  • Ability to speak Spanish preferred



Representative challenges of this position include having a high degree of competency/experience in general.  Requires good communication and organizational skills. Must Requires reasoning ability and good independent judgment.  Must project a professional image.  Working knowledge of personal computer and software applications used in job.



  • Responsible for phone-based interaction with patients after discharge
  • Inform patients of abnormal laboratory results
  • Educate patient and/or caregiver on disease specific education
  • Coordinate follow up care with Primary Care Physician or Specialist as necessary
  • Identify barriers to compliance with plan of care
  • Refer to Care Link Clinic when needed
  • Coordinate access to clinical and community based resources as appropriate
  • Respond to triggers that may indicate intervention is required
  • Assists with monitoring and continually assess the success of problem resolution activities.
  • Completes and maintains records for problem status for follow-up.                         
  • Maintains and distributes corrective action reminder report to responsible persons.
  • Assist with meetings and disseminates information to appropriate areas, as directed.
  • Able to travel and make home visits as needed.
  • All other duties as assigned.