Care Transition Manager, RN - PRN, Days

Texas Health Resources • IN

82d

About The Position

The Care Transition Manager RN – Case Management position at Texas Health Allen involves collaborating with physicians, staff, patients, and families to determine discharge needs. The role requires ensuring open communication through daily interdepartmental rounds with charge RNs, physicians, and Care Transition Managers (CTMs) to agree on discharge plans. The position is PRN, requiring 2-4 weekend shifts and weekday shifts to cover PTO or increased volumes, with shift times from 8:30 AM to 5:00 PM.

Requirements

• Bachelor’s degree in nursing required.
• Three years of experience as a Staff Nurse at an acute care hospital required.
• One year of discharge planning/care management preferred.
• RN – Registered Nurse upon hire required.
• CPR – Cardiopulmonary Resuscitation upon hire required.
• ACM – Accredited Case Manager upon hire preferred.
• CCM – Certified Case Manager upon hire preferred.
• Other – ANCC upon hire preferred.

Responsibilities

• Reviews the Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients.
• Collaborates with the interdisciplinary team to identify high-risk patients.
• Promotes discussion and assists in the identification of a primary care physician (PCP) for patients without one.
• Completes Transition Evaluations on patients within 24 hours of identification and begins discharge planning.
• Interviews and assesses patients and caregivers as part of the transition evaluation.
• Identifies transition needs and discusses funding of post-transition care with patients and caregivers.
• Identifies Geometric Mean Length of Stay (GMLOS) and updates the Anticipated Date of Discharge (ADOD) as necessary.
• Identifies community resources and service needs and facilitates appropriate referrals.
• Assigns patients to and supports appropriate transition programs when applicable.
• Communicates with the multidisciplinary team, patient, family, and post-acute care stakeholders to coordinate care.
• Educates patients, caregivers, and the multidisciplinary team regarding available post-acute care services.
• Executes and updates the discharge plan as needed.
• Communicates the final transition plan 24-48 hours prior to transition.
• Facilitates care conferences for complex transitions, placement, and palliative care needs.

Benefits

• 401k
• Employee Assistance Program (EAP)
• Discount Programs

What This Job Offers

• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees