Care Transition Manager, RN - PRN, Days

Texas Health Resources•Allen, TX

8d•Onsite

About The Position

The Care Transition Manager Registered Nurse (RN) - Care Management role at Texas Health Allen focuses on collaborating with physicians, staff, patients, and families to determine and ensure appropriate discharge needs are met. The role involves ensuring open communication through daily interdepartmental rounds with the charge RN, physicians, and other Care Transition Managers (CTMs) to ensure agreement on the discharge plan. The department offers a supportive environment with experienced coworkers.

Requirements

Bachelor's Degree 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

Collaborates with physicians, staff, patients, and families to determine discharge needs.
Ensures open communication with daily Interdepartmental rounds with charge RN, physicians and CTMs to ensure all agree of discharge plan.
Reviews the Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients.
Identifies 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.
Ensures patients are transitioned to appropriate levels of care in a timely and effective manner.