CARE TRANSITION MANAGER RN PRN

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Location:
Fort Worth, TX US
Job ID:
90380
Department:
Care Transitions
Area of Interest:
RN
Job Type:
PRN
Qualifications:
Overview:
Texas Health Southwest

Qualifications/Duties:
Candidate must be able to work a minimum of two weekend shifts per month.

Required minimum education: RN BSN required

Required minimum experience:
Min. five years clinical experience as staff nurse at an acute care hospital (required)
Min. two years acute care hospital discharge planning/care management (preferred)

Required license/certification:
Current RN licensure
CPR Certification preferred within 60 days of hire
ACM, ANCC, CCM or CM certification (preferred)
Required skills:
Competency in 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 and communication
Strong skills in the preparation of clinically pertinent medical record documentation
Critical thinking and analysis skills and conflict resolution skills
Position requires flexible scheduling, including weekend and evening shift work as necessary
Psychosocial and crisis intervention skills
Ability to prioritize and meet deadlines.
Preferred experience with electronic health record and automated case management systems.
Individual must be self-directed and goal/outcomes/measurement driven

Job reports to:
Care transitions entity Director, Manager or Lead
Actively participates in Daily Patient Care Briefings and identifies patients appropriate for transition needs intervention.
Reviews Readmission Risk Indicator (RRI) scores daily for all assigned patients.
Collaborates with interdisciplinary team to identify high risk patients whose RRI score may not have indicated appropriately.
Ensures all assigned patients have an identified Primary Care Physician (PCP). If PCP not identified, exhaust all efforts in an attempt to assign.
Completes Transition Evaluation on all identified patients within 24 hours of referral; documents appropriately.
Interviews/Assesses patients / caregivers as part of transition evaluation and as needed.
Identifies transition needs (including medications), develops transition plan within 24 hours of referral, and discusses funding of post transition care with patients / caregivers; documents appropriately.
Validates transition plan with Interdisciplinary Team (Physician, Clinical Nurse Leader, Nursing, etc.).
Updates Estimated Transition Date (ETD) as needed.
Educates interdisciplinary team and patients / caregivers regarding available post acute care services and needs.
Communicates transition plan and post acute management plan with patients / caregivers and post acute care stakeholders.
Executes and updates transition plan and post acute management plan as needed.
Facilitates care conferences for complex transitions and/or placement.
Identifies community resources / service needs; facilitates appropriate referrals as needed (acute and nonacute).
Actively communicates with all appropriate post acute care providers throughout patient stay.
Communicates final transition plan 24-48 hours prior to transition.
Serves as a point of contact for all identified stakeholders.
Assigns patients to appropriate transition program(s) (i.e. NTSP, THPG or based on payor preferences) and provides support as needed.

Serves as a content expert regarding payor information. Educates interdisciplinary team and patients / caregivers regarding payor requirements and / or barriers.
Facilitates care conferences for complex transitions and/or placement.
Identifies community resources / service needs; facilitates appropriate referrals as needed (acute and nonacute).
Communicates with payors as needed.

Monitors follow up activities for all appropriate patients post hospitalization and supports patient transition plan adherence.
Ensures transition plan and post-acute management plan consistency across care settings.
Proactively identifies patients who no longer meet current level of care / continued stay medical necessity criteria and communicates and documents appropriately.
Complies with all documentation requirements. Documents all activities in electronic health record.
Ensures scheduling of follow-up PCP appointment (for patients not served by CNL/ PCF).
Schedules clinic follow up appointments in cases in which a PCP is unable to be identified /assigned (for patients not served by CNL/PCF).

Ensures transition plan and post-acute management plan consistency across care settings.
Complies with all documentation requirements. Documents all activities in electronic health record.
Adheres to compliance requirements: Code 44 intervention, HINN letters, Second IMM, Observation letter, etc.
Has working knowledge of Advanced Directives, Living Will, Medical Power of Attorney, Mental Health Treatment Declaration, Out-of-Hospital Do Not Resuscitate Order and Advanced Illness Planning

Participates in Joint Commission readiness activities

Serves as a content expert on the following:
• Psychosocial issues related to hospitalization and transition planning
• Compliance with program expectations
• Mitigation activities with all clinical partners / payors as needed.
• Compliance requirements: Code 44 intervention, HINN letters, Second IMM, Observation letter, etc.
• Potential denials, avoidable days, alternate level of care days, etc.
• Medical necessity criteria, patient status, and discharge criteria.
• All clinical documentation
• Clinical Review staff requirements and communications


Entity Information:
Texas Health Harris Methodist Hospital Southwest Fort Worth is a 222-bed full-service facility that includes surgical and imaging services, a 24-hour emergency department, orthopedics and sports therapy, adult critical care, and a Level III neonatal intensive care unit. Texas Health Southwest Fort Worth, which has been serving Tarrant County residents since 1987, has 1,100 employees, 120 volunteers, and more than 600 physicians on its medical staff. The hospital is a Pathway to Excellence® designated hospital by American Nurses Credentialing Center, a designated UnitedHealth Premium Surgical Spine specialty center and has earned Quality Respiratory Care Recognition from the AARC.  We invite you to join us in furthering your career and our accomplishments and philosophy of excellence.
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