Care Transition Manager RN PRN

Texas Health Resources; Fort Worth (TX); On-site; USD 70,000 - 90,000; Part time

Benefits offered by this job

401k match

Free parking

Cafeteria discounts

Job summary

Texas Health Resources is looking for a Care Transition Manager RN - PRN at Texas Health Southwest Fort Worth. This role involves coordinating patient transitions from hospital to appropriate post-acute settings, with a focus on safe, timely discharges and interdisciplinary collaboration.

The ideal candidate holds a BSN, is a licensed RN in Texas or with a compact license, and has strong discharge planning and communication skills.

Qualifications

• BSN required; CTRN grandfathered if hired before May 11, 2017
• RN licensure in TX or compact licensure recognized on hire
• CPR certification required on hire
• 3 years as Staff Nurse in an acute care hospital
• 1 year discharge planning/care management preferred
• ACM or CCM credentials preferred

Responsibilities

• Ensure timely transitions to appropriate levels of care
• Review THRIL scores and identify high risk patients with the team
• Schedule PCP follow ups and coordinate post-discharge care
• Comply with documentation guidelines in the EHR
• Educate patients and families about post-acute care options
• Facilitate care conferences for complex transitions
• Coordinate with physicians, nursing, therapy and post-acute care stakeholders

Skills

RN experience

Discharge planning

Interdisciplinary collaboration

Communication skills

Microsoft Office

Education

BSN

RN licensure (TX or compact)

CPR certification

ACM/ CCM preferred

ANCC preferred

Tools

Microsoft Outlook

Microsoft Word

Microsoft Excel

Job description

Care Transition Manager RN - PRN

Bring your passion to Texas Health so we are Better + Together

26006013

Work location:

Texas Health Southwest Ft. Worth, 6100 Harris Parkway, Fort Worth, TX 76132

Work hours:

PRN: On an as needed basis, Monday-Friday Business Hours, Between the hours of 7:30AM-5:30PM with flexibility; some weekend coverage as well. Ideally between 2 to 3 days per week.

Care Transition Department Highlights

• Care Transition management - will float to various specialty areas as needed
• Magnet status, Level II Trauma facility, Stroke & Chest pain certified, Hip & Knee Orthopedics certified.
• Assessing patients for post-discharge needs
• Helping coordinate patient care to ensure safe transitions from the hospital

Here’s What You Need

• Bachelor of Science in Nursing (BSN) required; 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.
• RN – Registered Nurse Upon Hire Required; Current RN licensure or compact licensure recognized by the Texas Board of Nursing upon hire
• CPR – Cardiopulmonary Resuscitation required upon hire
• 3 Years Staff Nurse (RN) at an acute care hospital Required
• 1 Year discharge planning/care management preferred
• ACM - Accredited Case Manager Upon Hire Preferred Or

• CCM - Certified Case Manager Upon Hire Preferred Or
• Other ANCC Upon Hire Preferred

• Working knowledge of medical necessity criteria preferred
• Knowledge of Microsoft Outlook and Office (Word, Excel)
• Customer service skills, Psychosocial and crisis intervention skills
• Ability to engage in complex clinical decision-making, Critical thinking, analysis and conflict resolution skills
• Strong oral and written communication skills
• Strong commitment to interdisciplinary collaboration
• Flexible scheduling as necessary
• Ability to prioritize and meet deadlines

What You Will Do

• Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner:

Reviews the Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients and collaborates with the interdisciplinary team to identify high risk patients whose THRIL score may not have indicated appropriately.

• Promotes discussion and assists in the identification of a primary care physician (PCP) for patients without a PCP
• Completes Transition Evaluations on patients within 24 hours of identification and begins discharge planning.
• Interviews and assesses patients and caregivers as part of the transition evaluation and as needed.
• Identifies transition needs and discusses funding of post-transition care with patients and caregivers.
• Identifies Geometric Mean Length of Stay (GMLOS) and updates the Anticipated Date of Discharge (ADOD) as necessary while considering excess days risk.
• Identifies community resources and service needs and facilitates appropriate referrals as needed.
• Communicates with the multidisciplinary team (physicians, nursing, therapy), patient, family and post-acute care stakeholders in order to coordinate care.
• Educates, patients, caregivers, and the multidisciplinary team regarding available post-acute care services and needs.
• Facilitates care conferences for complex transitions, placement and palliative care needs.
• Proactively identifies patients who no longer meet continued stay criteria and communicates with the physician team.
• Attempts to schedule PCP, specialist or clinic follow up appointments for patients.
• Responsible for compliance with documentation guidelines and regulatory agency requirements:

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

Additional perks of being a Texas Health Care Transition Manager

• Benefits include 401k, free parking and discounts in the cafeteria.
• A supportive, team environment with outstanding opportunities for growth.
• Explore our Texas Health careers site for info like Benefits, Job Listings by Category, recent Awards we’ve won and more.

Do you still have questions or concerns?

Feel free to email your questions to [e-mail].