Registered Nurse- Care Transition Manager, Full time, Days

Texas Health Resources•Rockwall, TX

3d•Hybrid

About The Position

This is a full-time, day shift position for a Registered Nurse, Care Transition Manager at Texas Health Rockwall. The role involves ensuring patients are transitioned to appropriate levels of care in a timely and effective manner. The position is primarily for the ER and is part of a collaborative and highly engaged Care Transitions team focused on exceptional patient outcomes. There are opportunities to lead process improvement initiatives and a supportive leadership culture encourages professional development and growth.

Requirements

Bachelor’s Degree in Nursing required.
Current Registered Nurse (RN) licensure required upon hire.
Current CPR (Cardiopulmonary Resuscitation) certification required upon hire.
Minimum three (3) years of experience as a Staff Nurse in an acute care hospital required.
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.
Working knowledge of medical necessity criteria preferred.

Responsibilities

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.