Care Transition Manager RN - 36 hours (weekends only)

#REF!•Fort Worth, TX

2d•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 reviewing Risk of Unplanned Readmission (RUR) scores daily, identifying transition needs, discussing funding of post-transition care with patients and caregivers, and coordinating with patients and families to manage chronic conditions and ensure appropriate post-discharge clinical follow-up. The position also involves assigning patients to and supporting appropriate transition programs and complying with all documentation requirements by documenting all activities in the electronic health record. Texas Health Fort Worth is an 851-bed, Magnet-designated, full-service hospital that has served the Fort Worth community since 1930, offering advanced care in various specialties and recognized for its high-acuity capabilities and commitment to training future physicians. The hospital is Joint Commission-certified in several areas and recognized as a top choice for emergency services, women's health, and cardiac care.

Requirements

Bachelor’s degree in Nursing (BSN) required.
3 years staff nurse at an acute care hospital required
RN – Registered Nurse upon hire required
CPR – Cardiopulmonary Resuscitation upon hire required

Nice To Haves

1 year discharge planning/care management highly preferred
ACM – Accredited Case Manager upon hire preferred
CCM – Certified Case Manager upon hire preferred
ANCC upon hire preferred

Responsibilities

Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner
Reviews the Risk of Unplanned Readmission (RUR ) scores daily for all assigned patients.
Identifies transition needs and discusses funding of post-transition care with patients and caregivers.
Coordinates with patients and families to manage chronic conditions and ensures appropriate post-discharge clinical follow up.
Assigns patients to and supports appropriate transition programs (e.g. ACO members) when applicable
Complies with all documentation requirements and documents all activities in the electronic health record