Texas Health Resources CARE TRANSITION MGR RN PRN in Plano, Texas

Job Description

Education

Bachelor's Degree Nursing Req

Experience

3 Years Staff Nurse at an acute care hospital Req

2 Years Acute care hospital discharge Pref

Licenses and Certifications

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

Skills

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

Supervision

Individual Contributor

ADA Requirements

Extreme Heat 1-33%

Extreme Cold 1-33%

Extreme Swings in Temperature 1-33%

Extreme Noise 1-33%

Working Outdoors 1-33%

Working Indoors 67% or more

Mechanical Hazards 1-33%

Electrical Hazards 1-33%

Explosive Hazards 1-33%

Fume/Odor Hazards 1-33%

Dust/Mites Hazards 1-33%

Chemical Hazards 1-33%

Toxic Waste Hazards 1-33%

Radiation Hazards 1-33%

Wet Hazards 1-33%

Heights 1-33%

Other Conditions 1-33%

Physical Demands

Light Work

Qualifications

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. 60%

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 adherence.

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) 20%

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 20%

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.