Care Transition Nurse | Discharge & Care Coordination Leader

Texas Health Resources; Texas; Hybrid; USD 85,000 - 105,000; Full time

Benefits offered by this job

401k plan

PTO

Medical insurance

Dental insurance

Paid Parental Leave

Tuition reimbursement

Job summary

Texas Health Resources seeks a Registered Nurse, Care Transition Manager, to oversee patient transitions from the ER to appropriate post-acute care. You will begin discharge planning early, coordinate with multi-disciplinary teams, and ensure timely transitions to improve outcomes.

Requirements include a BSN and 3+ years in acute care; case management and discharge planning experience preferred. Role offers growth opportunities and a hybrid work model with day shifts in Rockwall.

Qualifications

• Bachelor’s Degree in Nursing required.
• Minimum three years as Staff Nurse in acute care hospital required.
• Prior acute care case management and discharge planning experience preferred.

Responsibilities

• Ensure timely and effective patient transitions to appropriate care levels; perform Transition Evaluations and gather Social Determinants of Health data.
• Review daily RUR scores, identify transition needs, discuss funding for post-transition care, update discharge plans, and finalize plans 24–48 hours before transition.
• Participate in multidisciplinary rounds, coordinate care with team, patients, families, and post-acute stakeholders; resolve barriers to discharge.
• Assist in determining level and type of care needed; coordinate care progression; promote cost-effectiveness and arrange follow-up post-acute services.
• Ensure post-acute options are provided based on clinical necessity and patient choice; schedule post-acute care services and follow-up.

Skills

Critical thinking

Analytical skills

Conflict resolution

Verbal and written communication

Interdisciplinary collaboration

Customer service

Relationship building

Flexibility

Education

Bachelor’s Degree in Nursing

Tools

Microsoft Office (Outlook, Word, Excel)

Job description

Texas Health Resources seeks a Registered Nurse, Care Transition Manager, to oversee patient transitions from the ER to appropriate post-acute care. You will begin discharge planning early, coordinate with multi-disciplinary teams, and ensure timely transitions to improve outcomes.

Requirements include a BSN and 3+ years in acute care; case management and discharge planning experience preferred. Role offers growth opportunities and a hybrid work model with day shifts in Rockwall.