RN Care Transition Manager - Care Management - PRN

Fast-paced, high volume Care Transition department is looking for top nurses.

Is that you?

Work location: Texas Health Frisco, 12400 Dallas Parkway NB, Frisco, TX 75033

Work hours: PRN - As needed; 8a - 4:30p; Some weekdays, holiday and weekends

Care Transition Department highlights:

• Engaged leadership team
• Manageable case load
• Team that works together to ensure work/life balance for all

Here's What You Need

• Bachelor's Degree in Nursing required.
• Three years Staff Nurse at an acute care hospital required and
• One year discharge planning/care management 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 or
• Other - ANCC upon hire preferred.

What You Will Do

Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner:

• Reviews the Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients and collaborates with the interdisciplinary team to identify high risk patients whose THRIL score may not have indicated appropriately.
• Promotes discussion and assists in the identification of a primary care physician (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 the transition evaluation and as needed.
• Identifies transition needs and discusses funding of post-transition care with patients and caregivers.
• Identifies Geometric Mean Length of Stay (GMLOS) and updates the Anticipated Date of Discharge (ADOD) as necessary while considering excess days risk.
• Identifies community resources and service needs and facilitates appropriate referrals as needed.
• Assigns patients to and supports appropriate transition programs (e.g. ACO members) when applicable.
• Communicates with the multidisciplinary team (physicians, nursing, therapy), patient, family, and post-acute care stakeholders in order to coordinate care.
• Educates, patients, caregivers, and the multidisciplinary team regarding available post-acute care services and needs.
• Executes and updates the discharge plan as needed.
• Communicates final transition plan 24-48 hours prior to transition.
• Facilitates care conferences for complex transitions, placement, and palliative care needs.
• Reviews the Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients
• Identify high risk patients whose THRIL score
• Promotes discussion and assists in the identification of a primary care physician (PCP) for patients
• Completes Transition Evaluations on patients within 24 hours of identification and begins discharge planning
• Interviews and assesses patients and caregivers as part of the transition evaluation
• Identifies transition needs and discusses funding of post-transition care with patients and caregivers

Additional perks of being a Texas Health Nurse

• Benefits include 401k, PTO, medical, dental, Paid Parental Leave, flex spending, tuition reimbursement, Student Loan Repayment 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.
• Explore our for info like Benefits, Job Listings by Category, recent Awards we've won and more.

Do you still have questions or concerns? Feel free to email your questions to recruitment@texashealth.org.

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