RN, Care Transition Manager - Emergency

Texas Health Resources
Plano, TX 75093
Post Date:
July 10, 2024
Job Status:
$37.17 - $51.40

Texas Health Resources seeks to hire a Care Transition Manager, Registered Nurse – Emergency Department to join the Care Management Team at Texas Health Plano.

The address is Texas Health Plano, 6200 West Parker Road, Plano, Texas, 75093.

Salary: Min $37.17– Max $51.40, based on relevant work experience.


  • Part-Time, 40 Hours; First shift

As a Care Transition Manager/Registered Nurse with Texas Health Resourcesthis position is responsible for ensuring patients are timely and effectively transitioned to appropriate levels of care.

The essential duties of this position are:

  • Actively participates in Daily Patient Care Briefings and identifies patients appropriate for transition needs intervention.

  • Review Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients.

  • 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.

  • 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.

  • 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 the patient's stay.

  • 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.

  • Facilitates care conferences for complex transitions and/or placement.

  • Identifies community resources/service needs and facilitates appropriate referrals as needed (acute and non-acute).

  • Communicates with payors as needed.

  • Monitors follow up activities for all appropriate patients post-hospitalization and support patient transition plan adherence.

  • Pro-actively identifies patients who no longer meet the current level of care / continued stay medical necessity criteria and communicates and documents appropriately.

  • Complies with all documentation requirements. Documents all activities in the electronic health records.

  • Ensures scheduling of follow-up

  • Responsible for compliance with documentation guidelines as well as regulatory agencies.

The ideal candidate will possess the following qualifications:

  • Bachelor's Degree Nursing Individuals hired as CTRN prior to May 11, 2017, will be grandfathered to the CTRN position with an RN, at the entity they were employed at on May 11, 2017, required

  • 3 Years Staff Nurse at an acute care hospital Required

  • 2 Years Hospital Case Management experience Highly Preferred

  • Experience with Emergency Department Case Management Preferred

  • 2 Years Acute care hospital discharge Preferred

  • Oncology Experience Preferred

  • RN - Registered Nurse Upon Hire Required

  • CPR - Cardiopulmonary Resuscitation Upon Hire Required And

  • ACM - Accredited Case Manager Upon Hire Preferred Or

  • CCM - Certified Case Manager Upon Hire Preferred Or

  • Other ANCC Upon Hire Preferred


  • 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

  • Psychosocial and crisis intervention skills.

  • Ability to prioritize and meet deadlines.

  • Preferred experience with electronic health records and automated case management systems.

  • Individual must be self-directed and goal/outcomes/measurement driven


Texas Health Presbyterian Hospital Plano is a 366-bed, Magnet-designated hospital and recognized clinical leader, providing technologically advanced care to Plano, Frisco, and surrounding communities since 1991. This full-service facility features a full range of specialties including emergency medicine, cardiology, adult and adolescent behavioral health, pediatrics, an adult intensive care unit, state of the art and technologically advanced surgical services, and a Level III NICU. Texas Health Plano has more than 1,600 employees and over 1,360 physicians on its medical staff in more than 65 specialties. The hospital is an Advanced Level III Trauma Facility, accredited Chest Pain Center by The Joint Commission, named “Best Place to Have a Baby” in Collin County and a Gold-Level Mother Friendly business. Texas Health Plano is the recipient of the Disease-Specific Care Certifications from the Joint Commission in Chest Pain, Joint Replacement – Hip and Joint Replacement – Knee, and an Advanced Certification as a Primary Stroke Center. We invite you to join us in furthering your career and our accomplishments and philosophy of excellence.

Texas Health Highlights

  • 2019 FORTUNE Magazine's “100 Best Companies to Work For®”

  • Employees' Choice “Best Places to Work” by Glassdoor

  • A “Best Workplaces in Texas” by Fortune and Great Place to Work®

  •  2019 “20 Best Workplaces in Health Care and Biopharma” by Great Place to Work® and Fortune (ranked #1)

  • A 2019 Gold level LearningElite award – national list of best organizations for learning and development by Chief Learning Officer magazine

  • A 2019 “America's Best Employers for Diversity” list by Forbes


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