Care Transition Manager, RN - PRN, Days

26002151

Care Transition Manager RN – Case Management

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

Work location: Texas Health Plano, 6200 West Parker Road, Plano TX 75093

Work hours: PRN (Weekdays/weekends. 3 shifts minimum per schedule (which runs a month). Two holidays per year required

Care Management Highlights

• Flexible daytime hours
• Opportunity to work with a diverse group of highly educated professionals
• Care coordination with focus on timely discharges
• Ability to pick your own schedule
• Multidisciplinary team focus
• Team oriented with focus on providing compassionate patient centered care
• Evidence based practice
  
  

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!

Entity Highlights

Texas Health Plano Highlights:

Texas Health Presbyterian Hospital Plano is a 366-bed, Magnet-designated hospital and recognized clinical leader, providing technologically advanced care to Plano, Frisco and surrounding communities since 1991. This full-service facility features a full range of specialties including emergency medicine, cardiology, adult and adolescent behavioral health, pediatrics, an adult intensive care unit, state of the art and technologically advanced surgical services and Level III NICU. Texas Health Plano has more than 1,600 employees and over 1,360 physicians on its medical staff in more than 65 specialties. The hospital is an Advanced Level III Trauma Facility, accredited Chest Pain Center by The Joint Commission, named “Best Place to Have a Baby” in Collin County and a Gold-Level Mother Friendly business. Texas Health Plano is the recipient of the Disease Specific Care Certifications from the Joint Commission in Chest Pain, Joint Replacement – Hip and Joint Replacement – Knee and an Advanced Certification as a Primary Stroke Center. We invite you to join us in furthering your career and our accomplishments and philosophy of excellence.

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