Care Transition Manager, RN - Full time

Texas Health•Dallas, TX

18h•Onsite

About The Position

The Care Transition Manager, RN supports timely and effective transitions to appropriate levels of care for assigned patients. The role reviews patient readmission risk, identifies high-risk patients, completes transition evaluations, and begins discharge planning. It also involves assessing patients and caregivers, identifying transition needs, and discussing funding for post-transition care. The position is based at Texas Health Dallas and works days, Monday through Friday, from 8:00 a.m. to 4:00 p.m.

Requirements

Bachelor's degree in Nursing.
Three years of experience as a staff nurse at an acute care hospital.
Registered Nurse (RN) license 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, or Certified Case Manager (CCM) certification upon hire, or another ANCC certification upon hire.

Responsibilities

Ensure patients are transitioned to appropriate levels of care in a timely and effective manner.
Review Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients.
Identify high-risk patients based on their THRIL scores.
Promote discussion and assist in identifying a primary care physician (PCP) for patients.
Complete Transition Evaluations within 24 hours of patient identification and begin discharge planning.
Interview and assess patients and caregivers as part of the transition evaluation.
Identify transition needs and discuss funding for post-transition care with patients and caregivers.