Registered Nurse, RN Care Transition Manager – PRN

Texas Health Resources•Roanoke, TX

7d•Onsite

About The Position

Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner. The Registered Nurse (RN) Care Transition Manager will complete Transition Evaluations and collect Social Determinants of Health (SDOH) data on patients within 48 hours of identification and begin discharge planning. This role involves assessing and interviewing patients and caregivers as part of this evaluation and as needed. The RN will also review the Risk of Unplanned Readmission (RUR) scores daily for all assigned patients and assist in identifying a primary care physician (PCP) for patients without one, attempting to schedule follow-up appointments prior to discharge.

Requirements

Bachelor's Degree Nursing
3 years of Staff Nurse at an acute care hospital is required.
Must hold an active RN license - Registered Nurse Upon Hire is required.
CPR – Cardiopulmonary Resuscitation is required upon hire.

Nice To Haves

Individuals hired as CTRN prior to May 11, 2017, will be grandfathered to the CTRN position with an RN, at the entity they were employed at on May 11, 2017.
1 year of discharge planning and/or care management is highly preferred.
ACM – Accredited Case Manager upon hire is preferred OR CCM – Commission for Case Manager Certification or other ANCC upon hire is preferred.

Responsibilities

Completes Transition Evaluations and collects Social Determinants of Health (SDOH) data on patients within 48 hours of identification and begins discharge planning.
Assesses and interviews patient and caregivers as part of this evaluation and as needed.
Reviews the Risk of Unplanned Readmission (RUR) scores daily for all assigned patients.
Assists in the identification of a primary care physician (PCP) for patients without a PCP and attempts to schedule follow up appointments with either a PCP, specialist, clinic, physician or other transitional care visit prior to discharge.