Care Transition Manager, RN - Full time, Days

Texas Health Resources • Plano, TX

10h • Onsite

About The Position

This full-time Care Transition Manager RN position is located at Texas Health Plano, 6200 West Parker Road, Plano TX 75093, with work hours from Monday to Friday, 8:00a to 4:30p, requiring two holidays. The role offers flexible daytime hours, an opportunity to work with diverse, highly educated professionals, and focuses on care coordination for timely discharges. It emphasizes a multidisciplinary and team-oriented approach to providing compassionate patient-centered care based on evidence-based practice. Texas Health Presbyterian Hospital Plano is a 366-bed, Magnet-designated hospital and a recognized clinical leader, providing technologically advanced care to Plano, Frisco, and surrounding communities since 1991. It is a full-service facility with specialties including emergency medicine, cardiology, behavioral health, pediatrics, an adult intensive care unit, surgical services, and a Level III NICU. The hospital has over 1,600 employees and more than 1,360 physicians across over 65 specialties. It is an Advanced Level III Trauma Facility, an accredited Chest Pain Center, and an Advanced Certification as a Primary Stroke Center.

Requirements

• Bachelor’s degree in nursing required.
• Three years Staff Nurse at an acute care hospital required.
• RN – Registered Nurse upon hire required.
• CPR – Cardiopulmonary Resuscitation upon hire required.

Nice To Haves

• One year discharge planning/care management preferred.
• ACM – Accredited Case Manager upon hire preferred.
• CCM – Certified Case Manager upon hire preferred.
• Other – ANCC upon hire preferred.

Responsibilities

• Ensure patients are transitioned to appropriate levels of care in a timely and effective manner.
• Review the Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients and collaborate with the interdisciplinary team to identify high risk patients whose THRIL score may not have indicated appropriately.
• Promote discussion and assist in the identification of a primary care physician (PCP) for patients without a PCP.
• Complete Transition Evaluations on patients within 24 hours of identification and begin discharge planning.
• Interview and assess patients and caregivers as part of the transition evaluation and as needed.
• Identify transition needs and discuss funding of post-transition care with patients and caregivers.
• Identify Geometric Mean Length of Stay (GMLOS) and update the Anticipated Date of Discharge (ADOD) as necessary while considering excess days risk.
• Identify community resources and service needs and facilitate appropriate referrals as needed.
• Assign patients to and support appropriate transition programs (e.g. ACO members) when applicable.
• Communicate with the multidisciplinary team (physicians, nursing, therapy), patient, family, and post-acute care stakeholders in order to coordinate care.
• Educate patients, caregivers, and the multidisciplinary team regarding available post-acute care services and needs.
• Execute and update the discharge plan as needed.
• Communicate final transition plan 24-48 hours prior to transition.
• Facilitate care conferences for complex transitions, placement, and palliative care needs.

Benefits

• Benefits include 401k, PTO, medical, dental, Paid Parental Leave, flex spending, tuition reimbursement, student loan repayment programs as well as several other benefits.
• Delivery of high quality of patient care through nursing education, nursing research and innovations in nursing practice.
• Strong Unit Based Council (UBC).
• A supportive, team environment with outstanding opportunities for growth.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees