Care Transitions Manager RN - Case Management

Company: Texas Health Resources
Location: Flower Mound
Posted on: January 24, 2023

Job Description:

Care Transitions Manager RNCare Transition Manager RN - PRN (As needed)

Care Management team is looking for a Care Transition Manager RN to join the team. Is that you?

Work location: 4400 Long Prairie Rd, Flower Mound, Texas 75028

Work hours: PRN ( as needed), shifts will be Monday - Friday from 7:30am - 4pm and weekend coverage once a month

CTM Department Highlights:

* Self-scheduling, with flexible hours allowing for work/life balance.
* Engaged co-workers throughout the hospital that support a cooperative team culture
* Community hospital known for excellent care and service to both their patients and employees.

Here's What You Need

* Bachelor's degree in Nursing 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.
* Bachelor's degree in Nursing preferred
* 3 years experience as a staff nurse at an acute care hospital experience required
* 1 year discharge planning/care management strongly preferred
* Texas RN license - upon hire required and
* CPR upon hire required
* ACM - Accredited care manager, CCM - certified case manager or ANCC upon hire preferred

What You Will Do

* 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.
* 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.
* Executes and updates the discharge plan as needed.
* Communicates final transition plan 24-48 hours prior to transition.
* Facilitates care conferences for complex transitions, placement and palliative care needs.
* Serves as a point of contact for all identified stakeholders.
* Ensures patients are provided post-acute options based on clinical necessity and patient choice while also considering the payor source:
* Serves as a content expert regarding payor information. Educates the multidisciplinary team, patients and caregivers regarding payor requirements and barriers.
* Communicates with payors as needed.
* 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
* Serves as a content expert on the following:
* 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 employee

* 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.

Keywords: Texas Health Resources, Flower Mound , Care Transitions Manager RN - Case Management, Executive , Flower Mound, Texas