Texas Health Resources Care Transition Manager RN-PRN in Plano, Texas
Hearts makes a difference! Texas Health Resources, One of FORTUNE 100 Best Companies to work for is dedicated to finding people to help us fulfill our commitment to make health care human again. We staff our exemplary hospital with health care professionals who approach every patient, every colleague, every physician and every family member with compassion. Come join us on our Journey as we rise to the next level.
Our Texas Health Presbyterian Plano location is seeking to hire a Care Transition Registered Nurse PRN as needed.
Schedule/Hours: PRN As Needed
Bachelor Degree in Nursing
RN - Registered Nurse Upon Hire
CPR - Cardiopulmonary Resuscitation. (Completed by June 30, 2018 or within 90 days of hire
ACM - Accredited Case Manager Upon Hire
ANCC Upon Hire
CCM Upon Hire X
3 Years Staff Nurse at an acute care hospital
2 Years Acute care hospital discharge 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 Texas Health Readmission Indicator List (THRIL) 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 non acute). 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.
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 a 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.
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.