LPN Transitional Care Coordinator (Waco, TX)

About Us 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.” Join Ennoble Care today! Ennoble Care is seeking a full-time  LPN (Licensed Practical Nurse) to serve as a  Transitional Care Coordinator within one or more of our partnered long-term care facilities in Waco, Texas . The right person for this role is reliable, self-motivated, vigilant, and compassionate. This is an integral, on-site role as part of our clinical care team, working closely alongside our providers in a family-practice-style model built around continuity, relationship-building, and patient-centered support. You'll get to know the residents (and their families) over time, monitor for changes in condition, and play a meaningful, hands-on role in helping people stay healthy, avoid unnecessary hospitalizations, and remain in their home -- where many of them want to be. We're proud of the culture we've built at Ennoble Care -- one that is positive, respectful, and rooted in genuine teamwork. People here are valued, supported in doing work that matters, and encouraged to maintain a healthy work-life balance. We invest in our team's growth through internal advancement opportunities based on performance, organizational needs, and role availability, because we believe that when our team thrives, so do our patients. ABOUT THE ROLE At Ennoble Care, our mission is simple: To care is an honor . For our patients, that means we come to you, we care for you, and we're here for you -- and that belief is at the heart of everything we do. As an LPN Transitional Care Coordinator, you'll bring that mission to life -- working 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 -- serving as a reliable communication bridge among residents, families, facility staff, and our Housecalls division -- keeping everyone informed and care on track. REQUIRED QUALIFICATIONS   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 No over-night shifts No on-call requirements Seven (7) company-paid holidays annually Ability to pass background check Transportation criteria: Valid, unencumbered driver's license Consistent and reliable transportation to fulfill the duties of this position Current auto insurance, with the ability to provide proof Please note, travel between facilities may be required KEY RESPONSIBILITIES Care Coordination & Transitional Care Management div]:bg-bg-000/50 [&_pre>div]:border-0.5 [&_pre>div]:border-border-400 [&_.ignore-pre-bg>div]:bg-transparent [&_.standard-markdown_:is(p,blockquote,h1,h2,h3,h4,h5,h6)]:pl-2 [&_.standard-markdown_:is(p,blockquote,ul,ol,h1,h2,h3,h4,h5,h6)]:pr-8 [&_.progressive-markdown_:is(p,blockquote,h1,h2,h3,h4,h5,h6)]:pl-2 [&_.progressive-markdown_:is(p,blockquote,ul,ol,h1,h2,h3,h4,h5,h6)]:pr-8"> _*]:min-w-0 gap-3 standard-markdown"> 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 Consistently 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  On-Site Clinical Support Maintain a consistent and reliable daily on-site presence in assigned facilities Build ongoing relationships with residents and their families, maintaining a consistent presence that reinforces trust and continuity of care over time Conduct routine and urgent vital sign collection as needed Perform regular patient check-ins to support care plans, follow-ups, and clini