Registered Nurse (RN) Care Transition Manager – Full Time

Texas Health Resources•Arlington, TX

2d•Onsite

About The Position

The Registered Nurse (RN) Care Transition Manager is responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner. This role involves completing transition evaluations, collecting Social Determinants of Health (SDOH) data, assessing patients and caregivers, and reviewing readmission risk scores. The RN will assist in identifying primary care physicians and scheduling follow-up appointments, identifying transition needs, and discussing funding for post-transition care. Participation in multidisciplinary rounds is crucial for identifying length of stay, expected discharge dates, discharge barriers, and potential denials. The role requires coordinating with patients, families, and the multidisciplinary team to manage chronic conditions and ensure appropriate post-discharge clinical follow-up. The RN will proactively identify patients who no longer meet continued stay criteria, assign patients to appropriate transition programs, update and execute discharge plans, and communicate the final transition plan. Facilitating care conferences for complex transitions, placement, and palliative care needs, and serving as a point of contact for stakeholders are also key responsibilities. The role involves identifying and resolving barriers to discharge, determining the level and type of care needed, and coordinating patient care progression to enhance clinical outcomes and safe discharge planning. Input into optimal resource utilization, promoting cost-effectiveness, and referring appropriate cases for social work intervention are also part of the role. Additionally, the RN ensures patients are provided post-acute options based on clinical necessity, patient choice, and payor source, reviewing care options, facilitating continuity of care within the Texas Health network, and scheduling follow-up appointments. Scheduling and coordinating patient clinical needs to appropriate post-acute care facilities based on clinical capabilities, quality outcomes, network preference, and patient choice is essential. Identifying community resources, facilitating referrals, and educating patients, caregivers, and the multidisciplinary team on available post-acute care services are also required. The RN will serve as a content expert regarding payor information, educating the team and patients on payor requirements and barriers, and communicating with payors as needed. Finally, the RN is responsible for compliance with documentation guidelines and regulatory agency requirements, including documenting all activities in the electronic health record and adhering to compliance requirements for document delivery. A working knowledge of Advanced Directives, Medical Power of Attorney, Application for Temporary Mental Health Treatment, and out-of-hospital Do Not Resuscitate orders is necessary. Participation in Joint Commission and other survey readiness activities is also expected.

Requirements

Bachelor's Degree Nursing
3 Years Staff Nurse at an acute care hospital
RN - Registered Nurse Upon Hire
CPR - Cardiopulmonary Resuscitation Upon Hire
Working knowledge of medical necessity criteria
Knowledge of Microsoft Outlook and Office (Word, Excel)
Customer service skills
Ability to engage in complex clinical decision-making
Strong oral and written communication skills
Strong commitment to interdisciplinary collaboration
Critical thinking, analysis and conflict resolution skills
Psychosocial and crisis intervention skills
Ability to prioritize and meet deadlines

Nice To Haves

1 Year discharge planning/care management
ACM - Accredited Case Manager Upon Hire
CCM - Certified Case Manager Upon Hire
Other ANCC Upon Hire

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 the 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, visiting physician or other transitional care visit prior to discharge.
Identifies transition needs and discusses funding of post-transition care with patients and caregivers.
Participates in multidisciplinary rounds (MDRs) to help identify current length of stay (LOS), expected discharge date, anticipated discharge disposition, barriers to discharge, avoidable days, and potential denials.
Communicates with the multidisciplinary team, patient, family, and post-acute care stakeholders to coordinate care.
Coordinates with patients and families to manage chronic conditions and ensures appropriate post-discharge clinical follow up.
Proactively identifies patients who no longer meet continued stay criteria and communicates with the physician team.
Assigns patients to and supports appropriate transition programs (e.g. ACO members) when applicable.
Updates and executes the discharge plan as needed.
Communicates final transition plan 24-48 hours prior to transition.
Facilitates care conferences for complex transitions, placement, and palliative care needs.
Serves as a point of contact for all identified stakeholders.
Proactively identifies and documents barriers to discharge while working to resolve them, including obstacles impeding diagnostic or treatment progress.
Assists in the determination of the level and type of care needed; coordinates/facilitates patient care progression throughout the continuum with the objective of enhancing quality clinical outcomes and safe discharge planning.
Provides input into the optimal utilization of resources; promotes cost-effectiveness & efficiency; communicates with UR nurse to confirm appropriateness.
Refers appropriate cases for social work intervention.
Ensures patients are provided post-acute options based on clinical necessity and patient choice while also considering the payor source.
Reviews care options and, as appropriate, utilizes existing protocols/processes to facilitate continuity of care within the Texas Health network and to ensure prompt and convenient scheduling of follow up appointments.
Schedule/coordinate patient clinical needs to the appropriate post-acute care facility based on facilities’ clinical capabilities/offerings, historical quality outcomes results, preferred network, and patient informed choice.
Identifies community resources and service needs and facilitates appropriate referrals as needed, while also providing education to patients, caregivers, and the multidisciplinary team regarding the available post-acute care services and needs.
Assists with referrals for community resources and service needs including housing, food, transportation, and other social and environmental issues affecting health.
Serves as a content expert regarding payor information. Educates the multidisciplinary team, patients and caregivers regarding payor requirements and barriers. Communicates with payors as needed to coordinate care.
Complies with all documentation requirements and documents all activities in the electronic health record.
Adheres to compliance requirements for delivery of various documents (e.g. HINN, IMM, MOON letters).
Has a working knowledge of the following documents: Advanced Directives, Medical Power of Attorney, Application for Temporary Mental Health Treatment, and out-of-hospital Do Not Resuscitate.
Participates in Joint Commission and other survey readiness activities.