Care Transition Manager RN PRN

Care Transition Manager RN –PRN· Work location: Texas Health Stephenville – 411 N. Belknap Street, Stephenville, TX 76104· Work hours: PRN: On an as needed basis, On-Call Minimum of 1 Saturday per month – Prefer 2 per month; Work 1-2 times every 2 weeks; Cover for vacations and sick leaveCare Transition Management highlights:Care Transition management – based on the Med/Surg floor, and will work with Med/Surg, ICU and ED patients – Coordinate care with the Hospitalist, Cardiologist, Family Practitioner and SurgeonsHere’s What You Need· 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 Resuscitation upon hire Required .· 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 OrCCM - Certified Case Manager Upon Hire Preferred OrOther ANCC Upon Hire PreferredWhat 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.· 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.· 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 forTemporary Mental Health Treatment, and out-of-hospital Do Not Resuscitate.Additional perks of being a Texas Health Care Transition Nurse· Benefits include for PRN: 401k, free parking and discounts in the cafeteria.· A supportive, team environment with outstanding opportunities for growth.· Explore our Texas Health careers site (https://jobs.texashealth.org/) for info like Benefits (https://jobs.texashealth.org/benefits) , Job Listings by Category (https://jobs.texashealth.org/professions) , recent Awards (https://jobs.texashealth.org/awards) we’ve won and more.Do you still have questions or concerns? Feel free to email your questions to [email protected] .#LI-JH1Texas Health requires a resume when an application is submitted.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.