Care Transition Manager RN PRN

Texas Health Resources•Fort Worth, TX

3d•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 assessing patients for post-discharge needs, coordinating patient care to ensure safe transitions from the hospital, and floating to various specialty areas as needed. The position requires a strong understanding of medical necessity criteria, discharge planning, and community resources. The Care Transition Manager will collaborate with the interdisciplinary team, patients, and caregivers to facilitate smooth transitions and ensure compliance with documentation guidelines and regulatory requirements.

Requirements

Bachelor of Science in Nursing (BSN) required
RN – Registered Nurse Upon Hire Required
Current RN licensure or compact licensure recognized by the Texas Board of Nursing upon hire
CPR – Cardiopulmonary Resuscitation required upon hire
3 Years Staff Nurse (RN) at an acute care hospital Required
Knowledge of Microsoft Outlook and Office (Word, Excel)
Customer service skills
Psychosocial and crisis intervention skills
Ability to engage in complex clinical decision-making
Critical thinking, analysis and conflict resolution skills
Strong oral and written communication skills
Strong commitment to interdisciplinary collaboration
Ability to prioritize and meet deadlines

Nice To Haves

1 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
Working knowledge of medical necessity criteria preferred
Flexible scheduling as necessary

Responsibilities

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.
Communicates 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.
Facilitates care conferences for complex transitions, placement and palliative care needs.
Proactively identifies patients who no longer meet continued stay criteria and communicates with the physician team.
Attempts to schedule PCP, specialist or clinic follow up appointments for patients.
Complies with all documentation requirements and documents all activities in the electronic health record.
Adheres to compliance requirements for delivery of various documents (e.g. HINN, IMM, MOON letters).
Has a working knowledge of the following documents: Advanced Directives, Medical Power of Attorney, Application for Temporary Mental Health Treatment, and out-of-hospital Do Not Resuscitate.
Participates in Joint Commission and other survey readiness activities.