Texas Health Resources Care Transition Manager Registered Nurse Prn in Cleburne, Texas


Why Texas Health Resources?

Our facilities are located across the greater Dallas – Ft. Worth area with a centrally located corporate office in Arlington, TX. We are one of the largest faith-based, nonprofit health care delivery systems in the US that has the resources to offer a variety of career growth and professional development opportunities with equally remarkable benefits. Join our award-winning Texas Health family and contribute to our mission “to improve the health of the people in the communities we serve”. A few recent accomplishments we achieved include:

• 2018 FORTUNE Magazine’s “100 Best Companies to Work For®” (4th year in a row)

• 2015 “Healthiest Employer in North Texas” by Dallas Business Journal and 2015 Fortune “100 Best Workplaces for Millennials”

• Ranked #1 on the Fortune’s 2015 and 2016 “20 Best Workplaces in Health Care” and #2 on the nation's 50 Best Workplaces for Diversity for 2015 by Great Place to Work®

• 2015, 2016 and 2017 Platinum-level recognition from the American Heart Association (AHA) for being a “Fit-Friendly Worksite”

• 2015 Great Place to Work® and Fortune list of “50 Best Workplaces for Camaraderie”

• 2017 Becker's Healthcare "150 Great Places to Work in Healthcare" (3rd year in a row)

• Named by Hospital & Health Networks magazine as one of the nation’s 2016 “Most Wired” health care systems for the 16th time in 18 years

• Ranked #1 on 2016 and 2017 “100 Best Workplaces for Women list” by Great Place to Work®

• Platinum-level recognition in the 2016 and 2017 Best Employers for Healthy Lifestyles® awards, sponsored by the National Business Group on Health (ninth year to appear on the list and second year to receive the Platinum award

• Stage 7 Revalidation Texas Health Resources recently earned revalidation recognition for the premier award for electronic health record (EHR) adoption

Largest Blue Zones® Project Approved™ Worksite in the world (2016)

Texas Health Cleburne has an opportunity for a Prn Care Transition Manager.

PRN - Variable hours, weekday and weekend

Bachelor's Degree in Nursing Required

3 years experience in an acute care hospital required

2 years experience in acute care hospital discharge preferred

License / Certifications

RN Licensure upon hire

BCLS upon hire

ACM, ANCC, CCM preferred

Responsible for ensuring patients are timely and effectively transitioned to appropriate levels of care.

Actively participates in Daily Patient Care Briefings and identifies patients appropriate for transition needs intervention.

Reviews Readmission Risk Predictor (RRP) 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.).

Updates Estimated Transition Date (ETD) as needed.

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 nonacute).

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.

Assigns patients to appropriate transition program(s) (i.e. NTSP, THPG or based on payor preferences) and provides support as needed.

Ensures patients are placed appropriately following discharge and that necessary follow up takes place with patients

as well as payors.

Serves as a content expert regarding payor information. Educates interdisciplinary team and patients / caregivers

regarding payor requirements and / or barriers.

Facilitates care conferences for complex transitions and/or placement.

Identifies community resources/service needs; facilitiates appropriate referrals as needed (acute and non acute).

Communicates with payors as needed.

Monitors follow up activities for all appropriate patients post hospitalization and supports patient transition plan


Pro actively identitifies patients who no longer meet current level of care / continued stay medical necessity

criteria and communicates and documents appropriately.

Complies with all documentation requirements. Documents all activities in electronic health record.

Ensures scheduling of follow-up

PCP appointment (for patients not served by CNL/PCF)

Schedules clinic follow up appointments in cases in which a PCP is unable to be identified/assigned (for patients not served by CNL/PCF)

Responsible for compliance with documentation guidelines as well as regulatory agencies.

Ensures transition plan and post acute management plan consistency across care settings.

Complies with all documentation requirements. Documents all activities in electronic health record.

Adheres to compliance requirements: Code 44 intervention, HINN letters, Second IMM, Observation letter, etc.

Has working knowledge of Advanced Directives, Living Will, Medical Power of Attorney, Mental Health Treatment

Declaration, Out-of Hospital Do Not Resuscitate

Order and Advanced Illness Planning

Participates in Joint Commission readiness activities

Serves as a content expert on the following:

• Compliance with program expectations

• Mitigation activities with all clinical partners / payors as needed.

• Compliance requirements: Code 44 intervention, HINN letters, Second IMM, Observation letter, etc.

• Potential denials, avoidable days, alternate level of care days, etc.

• Medical necessity criteria, patient status, and discharge criteria.

• All clinical documentation

• Clinical Review staff requirements and communications

Entity Information:

Texas Health Harris Methodist Hospital Cleburne is a 137-bed, full-service hospital that has served Cleburne and the Johnson County area since 1986. Located about 35 miles south of Fort Worth, hospital services include surgery, women’s care, gastroenterology, orthopedics and ear, nose and throat care. The center has have over 80 physicians on its medical staff and has been recognized as a 2013 Top Performer for Quality Care in a nationwide performance improvement project, an accredited Chest Pain Center by the Society of Chest Pain Centers, and designated a Pathway to Excellence® hospital by the American Nurses Credentialing Center. Recognitions like these make our facility intensely qualified to serve our community and your professional aspirations.

Employment opportunities are only reflective of wholly owned Texas Health Resources entities.

We are an Equal Opportunity Employer and do not discriminate against any employees or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.