Care Transition Navigator | Part-Time RN Case Management

Texas Health Resources; Texas; On-site; USD 41,000 - 55,000; Part time

Benefits offered by this job

401k

Employee Assistance Program (EAP)

Discount Programs

Strong Unit Based Council (UBC)

Growth opportunities in team and care

Team environment with compassionate,患者

Job summary

Texas Health Plano is seeking a part-time Care Transition Manager RN to join the Case Management team. The role focuses on timely discharge planning, THRIL score review, and coordinating post-acute care with a multidisciplinary team.

Eligible candidates hold a BSN, have 3 years of staff nursing at an acute care hospital, CPR certification, and preferred CCM/ACM certifications. The position is on-site in Plano with flexible daytime hours, Friday-Sunday, 8:00am–5:00pm.

Qualifications

• Bachelor's degree in nursing required.
• Three years Staff Nurse at an acute care hospital required
• One year discharge planning/care management preferred
• RN - Registered Nurse upon hire required
• CPR - Cardiopulmonary Resuscitation upon hire required
• ACM - Accredited Case Manager upon hire preferred or CCM - Certified Case Manager upon hire preferred or Other - ANCC upon hire preferred.

Responsibilities

• Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner.
• Reviews THRIL scores daily and collaborates with the interdisciplinary team to identify high risk patients.
• Promotes discussion and assists in identification of a 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 transition evaluation.
• Identifies transition needs and discusses funding of post-transition care with patients and caregivers.
• Identifies GMLOS and updates the Anticipated Date of Discharge as necessary while considering excess days risk.
• Identifies community resources and facilitates referrals as needed.
• Assigns patients to and supports transition programs when applicable.
• Communicates with multidisciplinary team, patient, family, and post-acute care stakeholders to coordinate care.
• Educates patients, caregivers, and the team regarding post-acute care services and needs.
• Executes and updates the discharge plan; communicates final transition plan 24-48 hours prior to transition.
• Facilitates care conferences for complex transitions, placement, and palliative care needs.

Job description

Texas Health Plano is seeking a part-time Care Transition Manager RN to join the Case Management team. The role focuses on timely discharge planning, THRIL score review, and coordinating post-acute care with a multidisciplinary team.

Eligible candidates hold a BSN, have 3 years of staff nursing at an acute care hospital, CPR certification, and preferred CCM/ACM certifications. The position is on-site in Plano with flexible daytime hours, Friday-Sunday, 8:00am–5:00pm.