**Care Transition Manager RN – Care Management PRN Days** _We are looking for top skilled nurses to join our Texas Health family. Is that you?_ **Work location:** Texas Health Rockwall - 3150 Horizon Rd, Rockwall, TX 75032 **Work hours:** PRN “as needed” day schedule – Must be able to work mostly on the weekends along with some days during the week This position does not include medical benefits. **Care Management Department Highlights:** Supports the Emergency Department. Supportive team environment. Strong shared governance structure featuring unit-based councils that empower nurses to shape their work environment. New and advanced equipment and technology. **Here’s What You Need:** * 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 required * 3 years as a staff nurse at an acute care hospital required and * 1 year in discharge planning/care management preferred * RN - Registered Nurse required upon hire and * CPR - Cardiopulmonary Resuscitation required upon hire and * ACM - Accredited Case Manager preferred upon hire or * CCM - Certified Case Manager preferred upon hire or * ANCC - preferred upon hire **Skills:** Working knowledge of medical necessity criteria preferred Knowledge of electronic health record documentation preferred Knowledge of Microsoft Outlook and Office (Word, Excel) Strong oral and written communication skills Critical thinking, analysis, and conflict resolution skills Psychosocial and crisis intervention skills Ability to prioritize and meet deadlines **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. · 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 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. · Refers appropriate cases for social work intervention. · 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. · Responsible for compliance with documentation guidelines and regulatory agency requirements: Complies with all documentation requirements and documents all activities in the electronic health record. **Additional perks of being a Texas Health employee:** · Benefits include 401k · 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. **Entity Highlights:** Texas Health Hospital Rockwall is proud to serve the growing areas of Rockwall County, Kaufman County, Hunt County, eastern Dallas County, southern Collin County, and outlying areas. Our caregivers live in these tight knit communities too therefore we have a particular interest in providing the best care possible for you - our neighbors, friends, and family members. 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 recruitment@texashealth.org . \#LI-KC1 Texas 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.