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Texas Health Resources Care Transition Manager RN in Cleburne, Texas

Care Transition Manager RN

We’re looking for a qualified Care Transition Manager RN like you to join our Texas Health family.

Position Highlights

  • Work location: Texas Health Cleburne: 201 Walls Drive, Cleburne, TX 76033

  • Work environment: Care Management

  • Work hours: PRN (As Needed) rotating shift

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 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.

Qualifications

  • Bachelor's Degree Nursing Individuals hired as CTRN prior to May 11, 2017 will be grandfathered to the CTRN position with an RN, at the entity they were employed at on May 11, 2017.

Experience

  • 3 Years Staff Nurse at an acute care hospital required and

  • 1 Year discharge planning/care management preferred

License and Certifications

  • 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

Position Responsibilities

  • 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.

  • 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.

  • Serves as a point of contact for all identified stakeholders.

Ensures patients are provided post-acute options based on clinical necessity and patient choice while also considering the payor source:

  • Serves as a content expert regarding payor information. Educates the multidisciplinary team, patients and caregivers regarding payor requirements and barriers.

  • Communicates with payors as needed.

  • Proactively identifies patients who no longer meet continued stay criteria and communicates with the physician team.

  • Attempts to schedule PCP, specialist or clinic follow up appointments for patients.

Responsible for compliance with documentation guidelines and regulatory agency requirements:

  • Complies with all documentation requirements and documents all activities in the electronic health record.

  • Adheres to compliance requirements for delivery of various documents (e.g. HINN, IMM, MOON letters).

  • Has a working knowledge of the following documents: Advanced Directives, Medical Power of Attorney, Application for Temporary Mental Health Treatment, and out-of-hospital Do Not Resuscitate.

  • Participates in Joint Commission and other survey readiness activities.

Serves as a content expert on the following:

  • Compliance requirements for delivery of HINN, second IMM and MOON letters.

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

  • Medical necessity, patient status and discharge criteria.

  • Clinical review staff requirements and communications.

Why Texas Health As a Texas Health Care Transition Manager Social Worker you’ll enjoy top-notch benefits including 401(k) with match, paid time off, competitive health insurance choices, healthcare and dependent care spending account options, wellness programs to keep you and your family healthy, tuition reimbursement, a student loan repayment program and more.

Here are a few of our recent awards:

  • 2021 FORTUNE Magazine’s “100 Best Companies to Work For®” (7th year in a row)

  • Becker's Healthcare "150 Great Places to Work in Healthcare" (4 years running)

  • “America’s Best Employers for Diversity” list by Forbes

  • A “100 Best Workplaces for Millennials" by Fortune and Great Place to Work®

Explore our Texas Health careers site 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 .

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.

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