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Texas Health Resources Care Transition Manager RN/Registered Nurse, PRN, Stephenville in Stephenville, Texas

Care Transition Manager RN/Registered Nurse –

PRN – Flexibility!

Are you looking for a rewarding career, tight-knit nursing team and top-notch benefits? We’re looking for a qualified Registered Nurse like you to join our Texas Health family.

Position Highlights

  • Work location: Texas Health Stephenville – 411 N. Belknap Street, Stephenville, TX 76104

  • Work environment: Care Transition management – based on the Med/Surg floor, and will work with ICU and ED patients as well – Coordinate care with the Hospitalist, Cardiologist, Family Practitioner and Surgeons

  • Work hours: PRN: On an as needed basis, Monday to Friday, at least one ½ -day Saturday (08:00AM-12:00PM noon) of call per month; Open to them taking more call on weekends if available

  • Salary range: $37.17/hour to $55.05/hour + 401K retirement

  • Skills: Working knowledge of medical necessity criteria preferredKnowledge of Microsoft Outlook and Office (Word, Excel)Customer service skillsAbility to engage in complex clinical decision-makingStrong oral and written communication skillsStrong commitment to interdisciplinary collaborationCritical thinking, analysis and conflict resolution skillsFlexible scheduling as necessaryPsychosocial and crisis intervention skillsAbility to prioritize and meet deadlines

Texas Health Harris Methodist Hospital Stephenville is a full-service, 98-bed hospital serving Erath and surrounding counties since 1926. The hospital offers surgical services, women’s and infants’ services, advanced diagnostic imaging, sleep lab and a wound care program. Texas Health Stephenville has received accreditation as a Level IV trauma center, Cycle III Chest Pain Center by Society of Chest Pain Centers and Breast Imaging Center of Excellence. The hospital was named a Baby-Friendly Hospital by the World Health Organization and received Pathway to Excellence® designation by the American Nurses Credentialing Center. Stephenville is about an hour away from Fort Worth, so if peaceful surroundings in a rural area are the style you're looking for in your career, consider Texas Health Stephenville. You belong here.


  • Bachelor of Science in Nursing (BSN) required; 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.

  • Current RN licensure or compact licensure recognized by the Texas Board of Nursing upon hire

  • CPR – Cardiopulmonary Resuscitationrequired upon

  • 3 Years Staff Nurse (RN) at an acute care hospital Required

  • 1 Year discharge planning/care management preferred

  • 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.

Identifies community resources and service needs and facilitates appropriate referrals as needed.

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.

Facilitates care conferences for complex transitions, placement and palliative care needs.

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

Why Texas Health As a Texas Health RN, you’ll enjoy 401(k), free parking and discounts in the cafeteria.

At Texas Health, our people make this a great place to work every day. Our inclusive, supportive, excellence-driven culture make Texas Health a place you’ll love to call home.

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.