RN/Registered Nurse, Care Transition Manager, PRN, Days

Texas Health • Rockwall, TX

3d • Onsite

About The Position

Texas Health is hiring a PRN Registered Nurse, Care Transition Manager at Texas Health Rockwall. The position works days as needed, Monday through Friday, and includes two weekends per month, with flexibility to support departmental operations. It may have the potential to develop into a hybrid role.

The Care Transitions team collaborates with nursing, physicians, and interdisciplinary teams to support patient outcomes. The role helps patients transition to appropriate levels of care, supports discharge planning and post-discharge success, and contributes to improvements in length of stay, readmissions, and patient experience. The position is part of a supportive leadership and team environment that encourages professional development and growth.

Requirements

• Bachelor’s degree in Nursing required. Individuals hired into the Clinical Transition Registered Nurse (CTRN) role before May 11, 2017, are grandfathered into the CTRN position with an RN degree at the entity where they were employed on that date.
• At least three 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.
• Proficiency with Microsoft Office applications, including Outlook, Word, and Excel.
• Strong customer service and relationship-building skills.
• Ability to engage in complex clinical decision-making.
• Excellent verbal and written communication skills.
• 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.

Nice To Haves

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

Responsibilities

• Ensure patients transition to appropriate levels of care in a timely and effective manner.
• Complete Transition Evaluations, collect Social Determinants of Health (SDOH) data, begin discharge planning, and assess or interview patients and caregivers as needed.
• Review Risk of Unplanned Readmission (RUR) scores daily, identify transition needs, discuss funding for post-transition care, update and execute discharge plans, and communicate final transition plans 24–48 hours before transition.
• Participate in multidisciplinary rounds and coordinate care with the multidisciplinary team, patients, families, and post-acute care stakeholders.
• Identify and resolve barriers to discharge proactively.
• Help determine the level and type of care needed and coordinate or facilitate patient care progression across the continuum.
• Promote cost-effectiveness and efficiency, and refer appropriate cases for social work intervention.
• Ensure patients are offered post-acute options based on clinical necessity and patient choice.
• Schedule and coordinate post-acute care services, facilitate continuity of care, and arrange follow-up appointments.

Benefits

• Depending on status, benefits may include 401(k), paid time off (PTO), medical and dental coverage, Paid Parental Leave, flexible spending, tuition reimbursement, and student loan replacement programs.
• Supportive team environment with opportunities for growth.
• Professional development and growth support.

What This Job Offers

• Career Level: Mid Level