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Have a position you are looking to fill? CGEAN will post job openings for nursing administration positions for both members and non-members at no cost.  These positions will be available for all members and non-members to view.  Jobs will be listed for 60 days unless otherwise requested.  Email office@cgean.org  with your job posting. Please allow 3 - 5 business days from the time you send your request before your posting will be listed.   

Job Posting: November 6, 2017

Care Transition Manager, RN, PRN


Job ID: 90380
Location: Texas Health Southwest

Department:
Care Transitions
Area of Interest: RN  |  Job Type: PRN  |  Shift: 1st  |  Relocation Provided: No  |  Travel Required: No
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)


  • 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
Candidate must be able to work a minimum of two weekend shifts per month.

Apply Here: http://www.Click2apply.net/ydcctbd28s9464mq



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