Care Transition Manager, RN; Part time; Days

Texas Health Resources•Plano, TX

1d•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. The role works with patients, caregivers, the multidisciplinary team, and post-acute care stakeholders to coordinate care and plan discharges. It includes assessing transition needs, identifying community resources and appropriate referrals, discussing funding for post-transition care, and educating patients, caregivers, and team members about post-acute services. The position is based at Texas Health Plano in Plano, Texas, and is part-time, Friday through Sunday, from 8:00 a.m. to 5:00 p.m. The role offers flexible daytime hours, an opportunity to work with a diverse group of highly educated professionals, multidisciplinary and team-oriented collaboration, and a focus on compassionate, patient-centered care and evidence-based practice.

Requirements

Bachelor’s degree in nursing.
Three years of staff nurse experience at an acute care hospital.
Registered Nurse (RN) upon hire.
Cardiopulmonary Resuscitation (CPR) certification upon hire.

Nice To Haves

One year of discharge planning or care management experience.
Accredited Case Manager (ACM) certification upon hire.
Certified Case Manager (CCM) certification upon hire.
ANCC certification upon hire.

Responsibilities

Review THRIL scores daily for assigned patients and collaborate with the interdisciplinary team to identify high-risk patients whose scores may not have indicated risk appropriately.
Promote discussion and assist in identifying a primary care physician for patients who do not have one.
Complete Transition Evaluations within 24 hours of patient identification and begin discharge planning.
Interview and assess patients and caregivers as part of transition evaluations and as needed.
Identify transition needs and discuss funding of post-transition care with patients and caregivers.
Identify GMLOS and update the ADOD as necessary while considering excess-days risk.
Identify community resources and service needs and facilitate appropriate referrals.
Assign patients to and support appropriate transition programs, such as ACO programs, when applicable.
Communicate with physicians, nursing, therapy, patients, families, and post-acute care stakeholders to coordinate care.
Educate patients, caregivers, and the multidisciplinary team about available post-acute care services and needs.
Execute and update discharge plans as needed.
Communicate the final transition plan 24–48 hours before transition.
Facilitate care conferences for complex transitions, placement, and palliative care needs.