Care Transition Nurse-RN-PRN-Day Shift

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Cleburne, TX US
Job ID:
Care Transitions
Area of Interest:
Job Type:
Texas Health Cleburne

Texas Health Resources in Cleburne is seeking an RN to work with our Care Transition team on a PRN (as needed) basis. Qualified candidates will need to have availability to work day shift, on an as needed basis to provide back-fill support as well as additional coverage.

At Texas Health we are dedicated to finding people to help us fulfill our commitment to make health care human again. We staff our exemplary hospital with health care professionals who approach every patient, every colleague, every physician and every family member with compassion. Come join us on our Journey as we rise to the next level.

The ideal candidate will possess the following qualifications:

Required minimum education:
Graduate of a NLN (National League of Nursing) or CCNE (Commission on Collegiate Nursing Education) accredited nursing programs.

Required minimum experience:
Min. three years clinical experience as staff nurse in an acute care hospital (required)
Recent experience as hospital Case Manager/Care Manager/Care Transition Manager (preferred)

Required license/certification:
Current license to practice professional nursing (required)
CPR Certification within 30 days of hire (required)
CPUR CPHQ, CCS, CPUM or CM certification (preferred)
Required skills (if applicable):
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

B) Roles
• Actively participates in Daily Patient Care Briefings and identifies patients appropriate for transition needs intervention.
• Reviews Readmission Risk Predictor (RRP) scores daily for all assigned patients. Collaborates with interdisciplinary team to identify high risk patients whose RRP 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.
• 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 non-acute).
• Communicates with payors as needed.
• Assigns patients to appropriate transition program(s) (i.e. Healthways, NTSP, THPG or based on payor preferences) and provides support as needed.
• Monitors follow up activities for all appropriate patients post hospitalization and supports patient transition plan adherence.
• Escalates issues to appropriate level of CTM leadership and coordinates mitigation activities as needed.
• 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.
• 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.
• Participates in Joint Commission readiness activities.
• Proactively identifies and documents potential denials, avoidable days, alternate level of care days, etc.
• Collaborates with Clinical Review staff as needed.
• Serves as a content expert regarding medical necessity criteria, patient status and discharge criteria.
• Proactively identifies patients who no longer meet current level of care / continued stay medical necessity criteria and communicates and documents appropriately.

Entity Information:
Texas Health Harris Methodist Hospital Cleburne is a 137-bed, full-service hospital that has served Cleburne and the Johnson County area since 1986. Located about 35 miles south of Fort Worth, hospital services include surgery, women’s care, gastroenterology, orthopedics and ear, nose and throat care. The center has have over 80 physicians on its medical staff and has been recognized as a 2013 Top Performer for Quality Care in a nationwide performance improvement project, an accredited Chest Pain Center by the Society of Chest Pain Centers, and designated a Pathway to Excellence® hospital by the American Nurses Credentialing Center. Recognitions like these make our facility intensely qualified to serve our community and your professional aspirations.
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