Hearts makes a difference! Texas Health Resources, One of FORTUNE 100 Best Companies to work for is 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.
Our HEB (Hurst, Euless, Bedford) location is seeking to hire a Care Transition Registered Nurse full time.
Schedule/Hours: 8AM - 5PM
Essential Functions: Responsible for ensuring patients are timely and effectively transitioned 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 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. Minimum Education: Bachelor Degree in Nursing
License/Certification: RN - Registered Nurse Upon Hire
Preferred License/Certification: ACM - Accredited Case Manager Upon Hire ANCC Upon Hire CCM Upon Hire
Required Experience: 3 Years Staff Nurse at an acute care hospital 2 Years Acute care hospital discharge preferred