Care Transition Manager RN - Case Management _Bring your passion to Texas Health So We Are Better + Together!_ Work location: Texas Health Frisco, 12400 N Dallas Parkway, Frisco, TX 75033 Work hours: PRN; Some weekdays, weekends and holidays (8:30a-4:30p) Care Management Highlights * Engaged leadership team * Manageable case load * Team that works together to ensure work/life balance for all Here's What You Need * Bachelor's degree in nursing required. * Three years Staff Nurse at an acute care hospital required and * One year discharge planning/care management preferred * RN - Registered Nurse upon hire required and * CPR - Cardiopulmonary Resuscitation upon hire required and * ACM - Accredited Case Manager upon hire preferred or * CCM - Certified Case Manager upon hire preferred or * Other - 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. * Reviews the Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients * Identify high risk patients whose THRIL score * Promotes discussion and assists in the identification of a primary care physician (PCP) for patients * 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 * Identifies transition needs and discusses funding of post-transition care with patients and caregivers Additional perks of being a Texas Health Employee: * Benefits include 401k, Employee Assistance Program (EAP), Discount Programs, as well as other benefits. * Delivery of high-quality patient care * Strong Unit Based Council (UBC). * A supportive, team environment with outstanding opportunities for growth. Learn (https://jobs.texashealth.org/why-texas-health/) more about our culture, benefits, and recent awards! Entity Highlights: Texas Health Frisco is a 93-bed, acute-care, full-service hospital and medical office community offering primary care and multispecialty medicine. Our location in the North DFW area provides convenient care to the residents of Frisco and surrounding areas. We specialize in women's services, outpatient surgery, NICU and emergency medicine. Plus, we are a Pathway to Excellence Hospital, Joint Commission certified and we're a Baby Friendly designated facility. If you're ready to join us in our mission to improve the health of our community, then let's show the world how we're even better together! _Do you still have questions or concerns? Email your questions to:_ recruitment@texashealth.org \#LI-AW1 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.