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Texas Health Resources Care Transition Manager RN - Full Time, 40 Hours in Dallas, Texas

Texas Health Resources seeks to hire a Care Transition Manager/Registered Nurse to join the Care Management Team.

The address is Texas Health Dallas 8200 Walnut Hill Lane, Dallas, Texas, 75231.

Salary: Min $35.69 – Max $50.46, based on relevant work experience.


• Full-Time, 40 hours a week, 8:00am – 5:00pm, Monday - Friday

As a Care Transition Manager/Registered Nurse with Texas Health Resources , this position is responsible for ensuring patients are timely and effectively transitioned to appropriate levels of care.

The essential duties of this position are:

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

• Reviews Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients.

• 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.

• 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.

• 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 non acute).

• Actively communicates with all appropriate post acute care providers throughout patient stay.

• 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 and facilitates 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 adherence.

• Pro-actively identifies 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

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


The ideal candidate will possess the following 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 required

3 Years Staff Nurse at an acute care hospital Required

• 2 Years Acute care hospital discharge Preferred

• RN - Registered Nurse Upon Hire Required

• 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


Competency in medical necessity criteria preferred

Knowledge of Microsoft Outlook and Office (Word, Excel)

Customer service skills

Ability to engage in complex clinical decision-making

Strong oral and written communication skills

Strong commitment to interdisciplinary collaboration and communication

Strong skills in the preparation of clinically pertinent medical record documentation

Critical thinking and analysis skills and conflict resolution skills

Position requires flexible scheduling, including weekend and evening shift work as necessary

Psychosocial and crisis intervention skills.

Ability to prioritize and meet deadlines.

Preferred experience with electronic health record and automated case management systems.

Individual must be self-directed and goal/outcomes/measurement driven


Texas Health Presbyterian Hospital Dallas is an 898-bed, Magnet-designated hospital and recognized clinical program leader, having provided compassionate care to the residents of Dallas and surrounding communities since 1966. A full-service regional referral center, Texas Health Dallas has approximately 3,500 employees and 1,100 physicians on its medical staff, and offers a full range of services, including cancer care, cardiology, neurosciences, orthopedics, senior care, women's services and a renowned Level III neonatal intensive care unit. Texas Health Dallas has been recognized as a U.S. News and World Report Best Hospital in multiple specialties and is an accredited Cycle IV Chest Pain Center by the Society of Chest Pain Centers. The hospital is also a Bariatric Surgery Center of Excellence, a certified Emergency Stroke Care center and was named “Best Place to Have a Baby” in Dallas County in 2012.We invite you to join us in furthering your career and our accomplishments and philosophy of excellence.

Texas Health Highlights

2019 FORTUNE Magazine’s “100 Best Companies to Work For®”

Employees’ Choice “Best Places to Work” by Glassdoor

A “Best Workplaces in Texas” by Fortune and Great Place to Work®

2019 “20 Best Workplaces in Health Care and Biopharma” by Great Place to Work® and Fortune (ranked #1)

A 2019 Gold level LearningElite award – national list of best organizations for learning and development by Chief Learning Officer magazine

A 2019 “America’s Best Employers for Diversity” list by Forbes

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.