Registered Nurse- Care Transition Manager, Full time, Days

Texas Health•Rockwall, TX

2d•Hybrid

About The Position

Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner; completes Transition Evaluations and collects Social Determinants of Health (SDOH) data, begins discharge planning, and assesses/interviews patients and caregivers as needed. Reviews the Risk of Unplanned Readmission (RUR) scores daily, identifies transition needs, discusses funding of post-transition care, updates and executes discharge plans, and communicates final transition plans 24-48 hours prior to transition. Participates in multidisciplinary rounds (MDRs), coordinates care with the multidisciplinary team, patients, families, and post-acute care stakeholders, and proactively identifies and resolves barriers to discharge. Assists in determining the level and type of care needed, coordinates/facilitates patient care progression throughout the continuum, promotes cost-effectiveness and efficiency, and refers appropriate cases for social work intervention. Ensures patients are provided post-acute options based on clinical necessity and patient choice; schedules/coordinates post-acute care services, facilitates continuity of care, and arranges follow-up appointments. Delivery of high quality of patient care through nursing education, nursing research and innovations in nursing practice. Strong Unit Based Council (UBC). A supportive, team environment with outstanding opportunities for growth. This position will mainly be for the ER. Collaborative and highly engaged Care Transitions team focused on exceptional patient outcomes. Strong partnership with nursing, physicians, and interdisciplinary teams across the hospital. Opportunities to lead process improvement initiatives related to length of stay, readmission reduction, and patient experience. Supportive leadership culture that encourages professional development and growth. Meaningful work that directly impacts patients' transitions of care and post-discharge success.

Requirements

Bachelor’s Degree in Nursing required
Minimum three (3) years of experience as a Staff Nurse in an acute care hospital required
Current Registered Nurse (RN) licensure required upon hire
Current CPR (Cardiopulmonary Resuscitation) certification required upon hire
Proficient in Microsoft Office applications, including Outlook, Word, and Excel
Strong customer service and relationship-building skills
Demonstrated ability to engage in complex clinical decision-making
Excellent verbal and written communication skills
Strong commitment to interdisciplinary collaboration and teamwork
Critical thinking, analytical, and conflict-resolution abilities
Psychosocial assessment and crisis intervention skills
Ability to prioritize workload, manage multiple responsibilities, and meet deadlines
Flexibility to accommodate scheduling needs as required

Nice To Haves

Prior acute care case management and discharge planning experience is highly preferred
One (1) year of discharge planning and/or care management experience preferred
Leadership or supervisory experience is preferred
Accredited Case Manager (ACM) certification preferred
Certified Case Manager (CCM) certification preferred
American Nurses Credentialing Center (ANCC) certification preferred
Knowledge, Skills & Abilities Working knowledge of medical necessity criteria preferred

Responsibilities

Ensuring patients are transitioned to appropriate levels of care in a timely and effective manner
Completes Transition Evaluations and collects Social Determinants of Health (SDOH) data
Begins discharge planning
Assesses/interviews patients and caregivers as needed
Reviews the Risk of Unplanned Readmission (RUR) scores daily
Identifies transition needs
Discusses funding of post-transition care
Updates and executes discharge plans
Communicates final transition plans 24-48 hours prior to transition
Participates in multidisciplinary rounds (MDRs)
Coordinates care with the multidisciplinary team, patients, families, and post-acute care stakeholders
Proactively identifies and resolves barriers to discharge
Assists in determining the level and type of care needed
Coordinates/facilitates patient care progression throughout the continuum
Promotes cost-effectiveness and efficiency
Refers appropriate cases for social work intervention
Ensures patients are provided post-acute options based on clinical necessity and patient choice
Schedules/coordinates post-acute care services
Facilitates continuity of care
Arranges follow-up appointments