Care Transition Manager RN - 36 hours (weekends only)

Texas Health Resources•Fort Worth, TX

23h•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 daily review of the Risk of Unplanned Readmission (RUR) scores for assigned patients, identifying transition needs, and discussing funding of post-transition care with patients and caregivers. The position also coordinates with patients and families to manage chronic conditions and ensures appropriate post-discharge clinical follow-up. Additionally, the RN assigns patients to and supports appropriate transition programs when applicable and complies with all documentation requirements, recording all activities in the electronic health record.

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