• Texas Health Resources
  • $72,070.00 -98,340.00/year*
  • Bedford , TX
  • Healthcare - Nursing
  • Full-Time
  • 1505 Michael Dr

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Texas Health HEB seeks to hire a Registered Nurse Care Transition Manager Lead to work full-time.
The address is 1600 Hospital Parkway, Bedford, TX 76022

Salary range is Min. $39.03/hr to Max. $54.10/hr based on relevant experience
Work Schedule
Monday-Friday; 8a-5p
Essential Functions
  • Responsible for ensuring patients are moved timely and effectively to appropriate levels of care
  • Actively participates in Daily Patient Care Briefings and identifies patients appropriate for transition needs intervention.
  • Reviews Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients.
  • Collaborates with interdisciplinary team to identify high risk patients whose THRIL 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 tran Actively participates in Daily Patient Care Briefings and identifies patients appropriate for transition needs intervention.
  • Reviews THRIL 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.
  • Facilitates care conferences for complex transitions and/or placement.
  • Identifies community resources / service needs; facilitates appropriate referrals as needed (acute and non-acute).
  • 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.
  • Ensures patients are placed appropriately following discharge and that necessary follow up takes place with patients as well as payors.
  • Serves as a content expert regarding payor information.
  • Educates interdisciplinary team and patients / caregivers regarding payor requirements and / or barriers.
  • Communicates with payors as needed.
  • Monitors follow up activities for all appropriate patients post hospitalization and supports patient transition plan adherence.
  • 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).
  • Responsible for compliance with program expectations
  • Escalates issues to appropriate level of CTM leadership and coordinates mitigation activities as needed.
  • Ensures transition plan and post-acute management plan consistency across care settings.
  • As a Lead, is responsible for basic oversight of departmental activities as well as monitoring of work performance of the department.
  • 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.
  • Assures staff documentation is completed per guidelines as evidenced by appropriate monitoring techniques and staff are coached as needed.
  • Assists CTM manager, director or senior director to implement practice changes successfully.
  • Reports pertinent quality/risk issues to appropriate individuals, departments and/or committees in a timely manner.
  • Participates on performance improvement teams as appropriate.
  • Collaborates with the physician advisor as needed.
  • Participates in hospital/medical staff meetings to review patients meeting criteria related to high dollar/ extended length of stay and/or difficult placement; seeks assistance from CTM leadership as needed.
  • Assists CTM leadership to balance schedules to meet department needs.
  • Resolves daily staffing issues seeking assistance from CTM leadership as needed.
  • Demonstrates a positive problem-solving attitude to staff, physicians and peers.
  • Able to negotiate optimal resolution of issues.
  • Assists CTM leadership to remedy actual vs. expected customer satisfaction performance gaps as needed.
  • Discusses patient, staff, physician, and other department complaints with CTM leadership and follows up with a written report submitted within 24 hours as needed.
  • Responsible for compliance with documentation guidelines as well as regulatory requirements
  • 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.

Qualifications


The ideal candidate will possess the following qualifications

Education
Bachelor's Degree in Nursing required

Experience
Three (3) years Staff nurse at an acute care hospital required
One (1) year in Acute care hospital discharge required
Supervisory background preferred

Licenses and Certifications
RN - Registered Nurse upon hire required
CPR - Cardiopulmonary Resuscitation upon hire required
ACM - Accredited Case Manager upon hire preferred or
CCM - Certified Case Manager upon hire preferred or
ANCC upon hire

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
  • 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.


Why Texas Health Resources?
Texas Health Harris Methodist Hospital Hurst-Euless-Bedford is a 296-bed, acute-care facility serving Northeast Tarrant County since 1973. With more than 550 physicians on its medical staff, hospital services include outpatient surgery, women s services, a Level III neonatal intensive care unit, a dedicated oncology unit and cardiac rehabilitation. Texas Health HEB recently received a dual accreditation as a Cycle IV Chest Pain Center and Heart Failure Center by the Society of Chest Pain Centers, is certified as a Primary Stroke Center and a designated \"Baby Friendly\" facility by WHO and UNICEF. Our location brings the best of suburban living, offering you the benefits of convenience and solid career opportunities.
Texas Health Highlights
2018 FORTUNE Magazine s 100 Best Companies to Work For (4th year in a row)
2018 Becker's Healthcare \"150 Great Places to Work in Healthcare\" (4th year in a row)
2018 Employees Choice Best Places to Work by Glassdoor


Associated topics: cardiothoracic, domiciliary, infusion, intensive care, intensive care unit, nurse clinical, recovery, surgery, surgical, tcu

* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.

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