Care Transition Manager, RN; Part time; Days

Texas Health•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 conducts transition evaluations and discharge planning, identifies patient and caregiver needs, coordinates referrals and post-acute services, and works with patients, families, multidisciplinary teams, and post-acute care stakeholders to coordinate care. The position also supports complex transitions, placement, and palliative care needs through care conferences. This is a part-time, daytime position at Texas Health Plano in Plano, Texas, scheduled Friday through Sunday from 8:00 a.m. to 5:00 p.m. Care Management offers flexible daytime hours, the ability to pick a schedule, a multidisciplinary and team-oriented focus, and an emphasis 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 Texas Health Readmission Indicator List (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 identifying patients and begin discharge planning.
Interview and assess patients and caregivers as part of transition evaluations and as needed.
Identify transition needs and discuss funding for 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.
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 the discharge plan as needed.
Communicate the final transition plan 24–48 hours before transition.
Facilitate care conferences for complex transitions, placement, and palliative care needs.