Registered Nurse (RN) Care Transition Manager - Full Time

25010512 Registered Nurse (RN) Care Transition Manager - Full Time Work location : Texas Health Arlington 800 W. Randol Mill Road TX 76012 Work hours : Full Time - Days Department Highlights Team based environment. Workplace culture 2nd to none We operate on lean principles and rely on team atmosphere and individual performance. Highly engaged management What You Will Do Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner : Completes Transition Evaluations and collects Social Determinants of Health (SDOH) data on patients within 48 hours of identification and begins discharge planning. Assesses and interviews patient and caregivers as part of this evaluation and as needed. Reviews the Risk of Unplanned Readmission (RUR ) scores daily for all assigned patients. Assists in the identification of a primary care physician (PCP) for patients without a PCP and attempts to schedule follow up appointments with either a PCP, specialist, clinic, visiting physician or other transitional care visit prior to discharge. Identifies transition needs and discusses funding of post-transition care with patients and caregivers. Participates in multidisciplinary rounds (MDR?s) to help identify current length of stay (LOS), expected discharge date, anticipated discharge disposition, barriers to discharge, avoidable days, and potential denials. Communicates with the multidisciplinary team, patient, family, and post-acute care stakeholders to coordinate care. Coordinates with patients and families to manage chronic conditions and ensures appropriate post-discharge clinical follow up. Proactively identifies patients who no longer meet continued stay criteria and communicates with the physician team. Assigns patients to and supports appropriate transition programs (e.g. ACO members) when applicable Updates and executes 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. Proactively identifies and documents barriers to discharge while working to resolve them, including obstacles impeding diagnostic or treatment progress. Assists in the determination of the level and type of care needed; coordinates / facilitates patient care progression throughout the continuum with the objective of enhancing quality clinical outcomes and safe discharge planning. Provides input into the optimal utilization of resources; promotes cost-effectiveness & efficiency; communicates with UR nurse to confirm appropriateness Refers appropriate cases for social work intervention. 50% Ensures patients are provided post-acute options based on clinical necessity and patient choice while also considering the payor source : Reviews care options and, as appropriate, utilizes existing protocols / processes to facilitate continuity of care within the Texas Health network and to ensure prompt and convenient scheduling of follow up appointments. Schedule / coordinate patient clinical needs to the appropriate post-acute care facility based on facilities? clinical capabilities / offerings, historical quality outcomes results, preferred network, and patient informed choice Identifies community resources and service needs and facilitates appropriate referrals as needed, while also providing education to patients, caregivers, and the multidisciplinary team regarding the available post-acute care services and needs. Assists with referrals for community resources and service needs including housing, food, transportation, and other social and environmental issues affecting health . 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 to coordinate care. 30% 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 20% What You Need Education Bachelor's Degree Nursing 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. Req Experience 3 Years Staff Nurse at an acute care hospital Req and 1 Year discharge planning / care management Pref IP Acute Care Case Management Experience Preferred. 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 Or Other ANCC Upon Hire Pref Education Bachelor's Degree Nursing 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. Req Experience 3 Years Staff Nurse at an acute care hospital Req and 1 Year discharge planning / care management 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 Or Other ANCC Upon Hire Pref Skills Working knowledge of 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 Critical thinking, analysis and conflict resolution skills Flexible scheduling as necessary Psychosocial and crisis intervention skills Ability to prioritize and meet deadlines 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