Care Transition Manager (RN)

Work location : Texas Health Kaufman, 850 Ed Hall Drive Kaufman, TX 75142

Work hours: PRN Days - Weekend and holiday requirements

Work Environment: Care Management

Entity Information: Texas Health Presbyterian Hospital Kaufman is a 91-bed acute-care, full-service hospital serving Kaufman and Henderson counties and southern Dallas County since 1979. Hospital services include women’s care, cardiac rehabilitation, wound care and diagnostic and imaging services. Texas Health Kaufman was recently recognized as a Pathway to Excellence® hospital by the American Nurses Credentialing Center and is a Level IV Trauma Center. Our location, 35 miles southeast of downtown Dallas, brings all the perks of country living to your lifestyle and puts the city's best features within convenient reach.

Here’s What You Need

• Bachelor’s degree from an accredited Nursing program

• 3 years staff nurse at an acute care hospital required

• 1 year discharge planning/care management preferred

• RN - Registered Nurse Upon Hire Req And

• CPR - Cardiopulmonary Resuscitation Upon Hire Req And

• ACM - Accredited Case Manager Upon Hire Pref Or

• CCM - Certified Case Manager Upon Hire Pref Or

• Other ANCC Upon Hire Pref

What You Will Do

Responsible 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.

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

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.

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.

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

Additional perks of being a Texas Health Nurse

• Benefits include 401k, PTO, medical, dental, Paid Parental Leave, flex spending, tuition reimbursement, student Loan forgiveness as well as several other benefits.

• Delivery of high quality of patient care through nursing education, nursing research and innovations in nursing practice.

• Strong Unit Based Council (UBC).

• A supportive, team environment with outstanding opportunities for growth.

• 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 .

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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.