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

Texas Health Resources • Rockwall, TX

3d

About The Position

The Registered Nurse, Care Transition Manager is responsible for helping patients transition to appropriate levels of care in a timely and effective manner. The role completes transition evaluations, collects Social Determinants of Health (SDOH) data, begins discharge planning, and assesses or interviews patients and caregivers as needed. It reviews daily Risk of Unplanned Readmission (RUR) scores, identifies transition needs, discusses funding for post-transition care, updates and executes discharge plans, and communicates final transition plans 24–48 hours before transition.

The position participates in multidisciplinary rounds and coordinates care with the multidisciplinary team, patients, families, and post-acute care stakeholders. It proactively identifies and resolves discharge barriers; helps determine the level and type of care needed; coordinates care progression across the continuum; supports cost-effectiveness and efficiency; and refers appropriate cases for social work intervention. The role also ensures patients receive post-acute options based on clinical necessity and patient choice, coordinates post-acute services, supports continuity of care, and arranges follow-up appointments.

The position is based at Texas Health Rockwall, with potential to develop into a hybrid role. It is PRN, day shift, working as needed during the week, Monday through Friday, and two weekends per month, with flexibility as needed to support departmental operations. The Care Transitions team is collaborative and engaged, partners closely with nursing, physicians, and interdisciplinary teams, and offers opportunities to lead process improvement work related to length of stay, readmission reduction, and patient experience. The role has a direct impact on patients’ transitions of care and post-discharge success.

Requirements

• Bachelor’s degree in Nursing required.
• Minimum 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.
• 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.
• Individuals hired into the Clinical Transition Registered Nurse (CTRN) role before May 11, 2017, will be grandfathered into the CTRN position with an RN degree at the entity where they were employed on May 11, 2017.

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

• 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 and identify patients’ 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 multidisciplinary teams, patients, families, and post-acute care stakeholders.
• Proactively identify and resolve barriers to discharge.
• Help determine the level and type of care needed and coordinate or facilitate patient care progression throughout 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: 401(k), paid time off, medical and dental coverage, Paid Parental Leave, flexible spending, tuition reimbursement, and student loan replacement programs.
• Additional benefits are available; the posting does not specify them.
• Supportive team environment with opportunities for growth.
• Professional development and growth encouraged by supportive leadership.

What This Job Offers

• Career Level: Mid Level