$80K — $100K *
are Transition Managers are responsible for ensuring timely and effectively transition to appropriate care. The essential job duties for this position are:
• Actively participates in Daily Patient Care Briefings and identifies patients appropriate for transition needs intervention.
• Reviews Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients. Collaborates with interdisciplinary team to identify high risk patients whose RRP score may not have indicated appropriately.
• Ensures all assigned patients have an identified Primary Care Physician (PCP). If PCP not identified, exhaust all efforts in an attempt to assign.
• Completes Transition Evaluation on all identified patients within 24 hours of referral?? documents appropriately.
• Interviews/Assesses patients / caregivers as part of transition evaluation and as needed.
Identifies transition needs (including medications), develops transition plan within 24 hours of referral, and discusses funding of post transition care with patients / caregivers documents appropriately.
• Validates transition plan with Interdisciplinary Team (Physician, Clinical Nurse Leader, Nursing, etc.).
• Educates interdisciplinary team and patients / caregivers regarding available post acute care services and needs.
• Communicates transition plan and post acute management plan with patients / caregivers and post acute care stakeholders.
• Executes and updates transition plan and post acute management plan as needed.
• Facilitates care conferences for complex transitions and/or placement.
• Identifies community resources / service needs facilitates appropriate referrals as needed (acute and non acute).
• Actively communicates with all appropriate post acute care providers throughout patient stay.
• Communicates final transition plan 24-48 hours prior to transition. Serves as a point of contact for all identified stakeholders.
• Ensures patients are placed appropriately following discharge and that necessary follow up takes place with patients as well as payors.
• Compliance requirements: Code 44 intervention, HINN letters, Second IMM, Observation letter, etc.
• Perform other duties as assigned.
The ideal candidate will possess the following qualifications:
• Bachelor's Degree in Nursing required.
• 3 years Staff Nurse at an acute care hospital required
• 2 years acute care hospital discharge preferred
• Critical Care or Ortho experience preferred.
• RN - Registered Nurse upon hire required and
• CPR – Cardiopulmonary Resuscitation upon hire required and
• ACM – Accredited Case Manager upon hire preferred or
• CCM – Certified Case Manager upon hire preferred.
• Working knowledge medical necessity criteria preferred.
• 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 and communication.
• Strong skills in the preparation of clinically pertinent medical record documentation.
• Critical thinking and analysis skills and conflict resolution skills.
• Position requires flexible scheduling, including weekend and evening shift work as necessary.
• Psychosocial and crisis intervention skills.
• Ability to prioritize and meet deadlines.
• Preferred experience with electronic health record and automated case management systems.
Valid through: 9/7/2020
$80K — $150K
7 days ago