Care Transition Manager, RN - PRN, Days

25010729

Care Transition Manager RN – Case Management

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

Work location: Texas Health Allen, 1105 Central Expwy North, Allen, TX 75013

Work hours: PRN; 2-4 weekend shifts (minimum 2) with weekdays shifts to cover PTO or increased volumes. Shifts times are 8:30-5:00p.

Care Management Highlights

• Collaborates with physicians, staff, patients, and families to determine discharge needs.
• Ensure open communication with daily Interdepartmental rounds with charge RN, physicians and CTMs to ensure all agree of discharge plan
• Supportive experienced coworkers.
  
  

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.
• Communicate 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 Employee

• Benefits include 401k, Employee Assistance Program (EAP), Discount Programs, as well as other benefits.
• Delivery of high-quality patient care
• Strong Unit Based Council (UBC).
• A supportive, team environment with outstanding opportunities for growth.
  
  

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

Texas Health Allen has served the local community and surrounding areas of Collin County since 2000. We’re an 88-bed, acute-care, full-service hospital providing exceptional care to Allen, Lucas, Fairview, McKinney, Melissa, Wylie, and the surrounding cities. We specialize in robotic and minimally invasive surgery, advanced cardiology and electrophysiology services, orthopedic and spine services, and comprehensive women’s and infants’ care. Plus, we’re an Accredited Chest Pain Center and STEMI receiving facility with more than 500 physicians practicing in more than 25 specialties. Texas Health Allen is a Joint Commission-accredited Gold Seal Certified Chest Pain facility, Level II Maternal, Level II NICU, Chest Pain Accredited, a Breast Imaging Center of Excellence and a Pathways to Excellence-designated hospital. You belong here.

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!

Do you still have questions or concerns? Email your questions to: recruitment@texashealth.org