Care Transition Manager, RN - Full time, Days

#REF!•Plano, TX

1d•Onsite

About The Position

The Care Transition Manager, RN at Texas Health Presbyterian Hospital Plano is responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner. This involves daily review of Texas Health Readmission Indicator List (THRIL) scores, collaboration with interdisciplinary teams to identify high-risk patients, and assisting in identifying primary care physicians for patients without one. The role requires completing Transition Evaluations within 24 hours of identification, initiating discharge planning, and assessing patients and caregivers to identify transition needs and discuss funding for post-transition care. Key duties also include identifying Geometric Mean Length of Stay (GMLOS), updating Anticipated Date of Discharge (ADOD), identifying community resources, facilitating referrals, and assigning patients to appropriate transition programs. Communication with the multidisciplinary team, patients, family, and post-acute care stakeholders is crucial for care coordination and education regarding available services. The manager executes and updates discharge plans, communicates final transition plans 24-48 hours prior to transition, and facilitates care conferences for complex cases. Texas Health Presbyterian Hospital Plano is a 366-bed, Magnet-designated facility, recognized for technologically advanced care since 1991, serving Plano, Frisco, and surrounding communities. It boasts over 1,600 employees and 1,360 physicians, and is an Advanced Level III Trauma Facility, accredited Chest Pain Center, and a Primary Stroke Center. The Care Management team offers flexible daytime hours, a diverse professional environment, a focus on timely discharges, and a team-oriented approach to compassionate, patient-centered care based on evidence-based practice.

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

Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner
Reviews the Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients and collaborates with the interdisciplinary team to identify high risk patients whose THRIL score may not have indicated appropriately
Promotes discussion and assists in the identification of a primary care physician (PCP) for patients without a PCP
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 and as needed
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 while considering excess days risk
Identifies community resources and service needs and facilitates appropriate referrals as needed
Assigns patients to and supports 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
Educates, patients, caregivers, and the multidisciplinary team regarding available post-acute care services and needs
Executes and updates the discharge plan as needed
Communicates final transition plan 24-48 hours prior to transition
Facilitates care conferences for complex transitions, placement, and palliative care needs
Reviews the Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients
Identify high risk patients whose THRIL score
Promotes discussion and assists in the identification of a primary care physician (PCP) for patients
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

Benefits

401k
PTO
medical
dental
Paid Parental Leave
flex spending
tuition reimbursement
student loan repayment programs
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