Care Transition Manager - FT

  • Texas Health Hospital Rockwall
  • Rockwall, TX 75087
  • Nov 17, 2022

Job Description

Texas Health Rockwall is growing and has a great opportunity for an experienced RN Case Manager to join our team!  This is a full time position that includes some weekend rotation. Responsibilities include: Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner: Reviews readmission indicator scores and collaborates to identify high risk patients Promotes discussion and assists in the identification of a PCP for patients without Completes Transition Evaluations on patients within 24 hours and begins discharge planning Interviews and assesses patients and caregivers as part of the transition evaluation and as needed. Identifies transition needs and discusses funding of post-transition care with patients and caregivers Identifies Geometric Mean Length of Stay (GMLOS) and updates the Anticipated Date of Discharge (ADOD) as necessary while considering excess days risk Identifies community resources and service needs and facilitates appropriate referrals as needed Assigns patients to and supports appropriate transition programs (e.g. ACO members) when applicable. Communicates with multidisciplinary team, patient, family, and post-acute care stakeholders to coordinate care Educates, patients, caregivers, and the multidisciplinary team regarding available post-acute care services and needs Executes and updates the discharge plan as needed Communicates final transition plan 24-48 hours prior to transition Facilitates care conferences for complex transitions, placement, and palliative care needs Ensures patients are provided post-acute options based on clinical necessity and patient choice while also considering the payor source: Serves as a content expert regarding payor information Provides education regarding payor requirements and barriers Communicates with payors as needed Proactively identifies patients who no longer meet continued stay criteria and communicates with the physician team Attempts to schedule PCP, specialist or clinic follow up appointments Responsible for compliance with documentation guidelines and regulatory agency requirements: Complies with all documentation requirements and documents all activities Adheres to compliance requirements for delivery of various documents (e.g. HINN, IMM, MOON letters). Has a working knowledge of: Advanced Directives, Medical Power of Attorney, Application for Temporary Mental Health Treatment, and out-of-hospital Do Not Resuscitate Participates in Joint Commission and other survey readiness activities Serves as a content expert on the following: Potential denials, avoidable days, and alternate level of care days Medical necessity, patient status and discharge criteria Clinical review staff requirements and communications Qualifications: Bachelor’s Degree in Nursing required 3 years Staff Nurse at an acute care hospital required and 1 year discharge planning/care management preferred Working knowledge of medical necessity criteria preferred. Ability to engage in complex clinical decision-making. Strong oral and written communication skills. Strong commitment to interdisciplinary collaboration Licenses and Certifications: RN – Registered Nurse upon hire required and ACM – Accredited Case Manager upon hire preferred or CCM – Certified Case Manager upon hire preferred