Care Transition Manager RN - 40 hours

#REF!•Fort Worth, TX

2d•Onsite

About The Position

The Care Transition Manager RN is responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner. This role involves reviewing Risk of Unplanned Readmission (RUR) scores daily, identifying transition needs, discussing funding of post-transition care with patients and caregivers, and coordinating with patients and families to manage chronic conditions and ensure appropriate post-discharge clinical follow-up. The manager also assigns patients to and supports appropriate transition programs and complies with all documentation requirements, documenting all activities in the electronic health record. This position is located at Texas Health Fort Worth, an 851-bed, Magnet-designated, full-service hospital serving the Fort Worth community since 1930. The hospital offers advanced care in various specialties and is recognized for its high-acuity capabilities and commitment to training future physicians. Texas Health Fort Worth is a Joint Commission-certified Comprehensive Cardiac Center, Comprehensive Stroke Center, and Level I Trauma Center, and is recognized as the Best Place to Have a Baby in Tarrant County.

Requirements

Bachelor’s degree in Nursing (BSN) required.
3 years staff nurse at an acute care hospital required
RN – Registered Nurse upon hire required
CPR – Cardiopulmonary Resuscitation upon hire required

Nice To Haves

1 year discharge planning/care management highly preferred
ACM – Accredited Case Manager upon hire preferred
CCM – Certified Case Manager upon hire preferred
ANCC upon hire preferred
Individuals hired as a Care Transition Supervisor prior to May 11, 2017 will be grandfathered with an ADN at the entity they were employed at on May 11, 2017

Responsibilities

Ensuring patients are transitioned to appropriate levels of care in a timely and effective manner
Reviews the Risk of Unplanned Readmission (RUR ) scores daily for all assigned patients.
Identifies transition needs and discusses funding of post-transition care with patients and caregivers.
Coordinates with patients and families to manage chronic conditions and ensures appropriate post-discharge clinical follow up.
Assigns patients to and supports appropriate transition programs (e.g. ACO members) when applicable
Complies with all documentation requirements and documents all activities in the electronic health record