Minimum three years of experience as a Staff Nurse in an acute care hospital
Prior acute care case management and discharge planning experience preferred
One year of discharge planning and/or care management experience preferred
Current Registered Nurse (RN) licensure required upon hire
Current CPR certification required upon hire
Accredited Case Manager (ACM) certification preferred
Responsibilities
Ensure timely and effective patient transitions to appropriate levels of care
Review daily Risk of Unplanned Readmission scores and update discharge plans
Participate in multidisciplinary rounds and coordinate care with the team
Assist in determining care levels and facilitate patient care progression
Schedule and coordinate post-acute care services and follow-up appointments
Benefits
401k, PTO, medical, dental, and Paid Parental Leave
Tuition reimbursement and student loan replacement programs
Opportunities for nursing education and research
Supportive team environment with growth opportunities
Full Job Description
Registered Nurse, Care Transition Manager
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.
