Care Transition Manager, RN - PRN, Days

Texas Health Resources•Allen, TX

17h•Onsite

About The Position

The Care Transition Manager Registered Nurse (RN) - Care Management position at Texas Health Allen is responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner. This role involves collaborating with physicians, staff, patients, and families to determine discharge needs, ensuring open communication through daily interdepartmental rounds, and supporting experienced coworkers. The department highlights its collaborative approach and supportive environment.

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 or CCM - Certified Case Manager upon hire or other ANCC upon hire preferred

Responsibilities

Reviews the Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients
Identify 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
Collaborates with physicians, staff, patients, and families to determine discharge needs.
Ensure open communication with daily Interdepartmental rounds with charge RN, physicians and CTMs to ensure all agree of discharge plan.