LPN Transitional Care Coordinator (Waco, TX)

Ennoble Care is a mobile primary care, palliative care, and hospice service provider with patients in New York, New Jersey, Maryland, DC, Virginia, Oklahoma, Kansas, Pennsylvania, Texas, Florida, and Georgia. Ennoble Care’s clinicians go to the home of the patient, providing continuum of care for those with chronic conditions and limited mobility. Ennoble Care offers a variety of programs including remote patient monitoring, behavioral health management, and chronic care management, to ensure that our patients receive the highest quality of care by a team they know and trust. We seek individuals who are driven to make a difference and embody our motto, “To Care is an Honor.”

About the Role

As an LPN Transitional Care Coordinator, you'll work on-site within one or more of our partnered skilled nursing and rehabilitation facilities in Waco, Texas. Your focus will be transitional care management, attentive patient monitoring, and day-to-day collaboration with our clinical team and facility staff. You'll serve as a reliable communication bridge among residents, families, facility staff, and our Housecalls division, keeping everyone informed and care on track. This role is embedded within assigned facilities, requiring a consistent daily presence and strong relationship-building with facility staff.

Responsibilities

• Coordinate care for patients residing in skilled nursing and rehabilitation facilities using Ennoble Care's EMR.
• Facilitate transitional care management, ensuring services with the Housecalls division are initiated immediately upon a patient's discharge from the hospital.
• Expedite time to first provider visit for newly transitioned patients in accordance with established guidelines.
• Monitor patients attentively, communicate changes in condition promptly to the provider, initiate appropriate interventions, and escalate care as clinically indicated, including CCM-billable activities.
• Support care coordination efforts to reduce avoidable emergency department visits and hospital readmissions.
• Collaborate daily with providers and facility staff to ensure care plans are kept current and acted on.
• Maintain a consistent and reliable daily on-site presence in assigned facilities.
• Build ongoing relationships with residents and their families, reinforcing trust and continuity of care.
• Conduct routine and urgent vital sign collection as needed.
• Perform regular patient check-ins to support care plans, follow-ups, and clinical stability.
• Identify changes in patient condition and promptly communicate concerns to the clinical team.
• Serve as a key liaison between Ennoble Care providers, facility staff, residents, families, and the Housecalls team.
• Convert two (2) eligible patients per day to Ennoble Care's Housecalls program.
• Accurately document patient interactions, assessments, and care coordination activities in Ennoble Care’s EMR.
• Perform chart reconciliation to ensure accuracy and continuity of clinical records between Ennoble and facility records.
• Support onboarding and training of new Transitional Care Coordinators.
• Serve as a clinical mentor and resource for newly hired coordinators.
• Promote best practices in transitional care, communication, and facility-based care coordination.

Requirements

• Legally authorized to work in the United States of America.
• Active, unrestricted LPN license in the state of Texas.
• Minimum 1 year of patient-facing experience in a long-term care, skilled nursing, or transitional care setting.
• Comfortable communicating proactively throughout the day in person, by phone, via email, and through Microsoft Teams.
• Solid working knowledge of healthcare terminology and care coordination principles.
• Strong clinical assessment skills with the ability to identify and escalate changes in condition.
• Experience with EMR systems and clinical documentation; Point Click Care experience preferred.
• Proficient with Microsoft 365 including Excel, Outlook, Word, and Teams.
• Excellent communication and interpersonal skills, with a solid foundation in organization, time management, and clinical documentation.
• Capacity to work independently while collaborating closely with multidisciplinary teams.
• Ability to work full-time in an on-site role 5 days per week (days of week are flexible, weekends preferred) based in the Waco, Texas area. Daytime hours, approximately 8:00 a.m. to 5:00 p.m. CST.
• No evenings, overnight shifts, or on-call requirements.
• Seven (7) company-paid holidays annually.
• Ability to pass background check.
• Valid, unencumbered driver's license and consistent, reliable transportation to fulfill the duties of this position.
• Current auto insurance, with the ability to provide proof.

Travel between facilities may be required.

Benefits

• Full-time health benefits eligibility, including medical, dental, vision, and supplementary benefits such as life insurance, short-term and long-term disability, flexible spending accounts for medical and dependent care, accident, critical illness, and hospital indemnity.
• Paid time off and paid office holidays.
• Paid sick time.
• 401(k) with up to 3% company match.
• Referral program.
• Payactiv: pay-on-demand. Cash out earned money when and where you need it.

Pay

Starting salary: $55,000 annually with quarterly bonus opportunities based on performance. Mileage reimbursement eligibility when traveling between facilities.

Schedule

Full-time, on-site role 5 days per week (days of week are flexible, weekends preferred). Daytime hours, approximately 8:00 a.m. to 5:00 p.m. CST. No evenings, overnight shifts, or on-call requirements.