Registered Nurse- Care Transition Manager, Full time, Days

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

Registered Nurse, Care Transition Manager

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

Work location: Texas Health Rockwall, with the potential to develop into a hybrid role. Work hours: Full Time, Days working 40 hours weekly- Monday-Friday, with some weekend coverage at times, day shift, with flexibility as needed to support departmental operations. This position will mainly be for the ER.

Department highlights

• Collaborative and highly engaged Care Transitions team focused on exceptional patient outcomes.
• Strong partnership with nursing, physicians, and interdisciplinary teams across the hospital.
• Opportunities to lead process improvement initiatives related to length of stay, readmission reduction, and patient experience.
• Supportive leadership culture that encourages professional development and growth.
• Meaningful work that directly impacts patients' transitions of care and post-discharge success.

Here’s What You Need

• Bachelor’s Degree in Nursing required.
• Individuals hired into the Clinical Transition Registered Nurse (CTRN) role prior to May 11, 2017, will be grandfathered into the CTRN position with an RN degree at the entity where they were employed on May 11, 2017.
• Minimum three (3) years of experience as a Staff Nurse in an acute care hospital required.
• Prior acute care case management and discharge planning experience is highly preferred.
• One (1) year of discharge planning and/or care management experience preferred.
• Leadership or supervisory experience is preferred.
• Current Registered Nurse (RN) licensure required upon hire.
• Current CPR (Cardiopulmonary Resuscitation) certification required upon hire.
• Accredited Case Manager (ACM) certification preferred.
• Certified Case Manager (CCM) certification preferred.
• American Nurses Credentialing Center (ANCC) certification preferred.

Knowledge, Skills & Abilities

• Working knowledge of medical necessity criteria preferred.
• Proficient in Microsoft Office applications, including Outlook, Word, and Excel.
• Strong customer service and relationship-building skills.
• Demonstrated ability to engage in complex clinical decision-making.
• Excellent verbal and written communication skills.
• Strong commitment to interdisciplinary collaboration and teamwork.
• Critical thinking, analytical, and conflict-resolution abilities.
• Psychosocial assessment and crisis intervention skills.
• Ability to prioritize workload, manage multiple responsibilities, and meet deadlines.
• Flexibility to accommodate scheduling needs as required.

What You Will Do

• Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner; completes Transition Evaluations and collects Social Determinants of Health (SDOH) data, begins discharge planning, and assesses/interviews patients and caregivers as needed.
• Reviews the Risk of Unplanned Readmission (RUR) scores daily, identifies transition needs, discusses funding of post-transition care, updates and executes discharge plans, and communicates final transition plans 24-48 hours prior to transition.
• Participates in multidisciplinary rounds (MDRs), coordinates care with the multidisciplinary team, patients, families, and post-acute care stakeholders, and proactively identifies and resolves barriers to discharge.
• Assists in determining the level and type of care needed, coordinates/facilitates patient care progression throughout the continuum, promotes cost-effectiveness and efficiency, and refers appropriate cases for social work intervention.
• Ensures patients are provided post-acute options based on clinical necessity and patient choice; schedules/coordinates post-acute care services, facilitates continuity of care, and arranges follow-up appointments.

Additional perks of being a Texas Health employee

• Depending on status, benefits include 401k, PTO, medical, dental, Paid Parental Leave, flex spending, tuition reimbursement, student Loan replacement programs as well as several other benefits.
• Delivery of high quality of patient care through nursing education, nursing research and innovations in nursing practice.
• Strong Unit Based Council (UBC).
• A supportive, team environment with outstanding opportunities for growth.

Learn more about our culture, benefits, and recent awards.

If you’re ready to join us in our mission to improve the health of our community, then let’s show the world how we’re even better together!