Title: RN Care Transition Manager
Department: Case Management
Shift: Days 8 hours (Mon - Fri)
Location: Dallas, TX
Duration: 3 months (with possible extension)

Job Summary: The RN Care Transition Manager is responsible for coordinating patient care across the continuum to ensure safe, efficient, and effective transitions from one level of care to another. This role involves collaboration with interdisciplinary teams, patients, and families to optimize health outcomes, reduce readmissions, and enhance patient satisfaction.

Key Responsibilities:

Care Coordination and Transition Planning:

• Develop and implement individualized care plans for patients transitioning between care settings (e.g., hospital to home, hospital to rehabilitation).
• Assess patient needs, preferences, and available resources to ensure a seamless transition.
• Collaborate with healthcare providers, community resources, and support services to coordinate care and services.

Patient and Family Education:

• Educate patients and their families about care plans, medications, follow-up appointments, and self-care management.
• Provide information and support regarding available resources and services to aid in the transition process.

Interdisciplinary Collaboration:

• Work closely with physicians, nurses, social workers, and other healthcare team members to ensure continuity of care.
• Participate in interdisciplinary team meetings and case conferences to review and discuss patient progress and care plans.

Monitoring and Evaluation:

• Monitor patient progress through follow-up calls, home visits, and coordination with outpatient providers.
• Evaluate the effectiveness of transition plans and make necessary adjustments to improve patient outcomes.

Documentation and Compliance:

• Maintain accurate and timely documentation of all care coordination activities in compliance with organizational policies and regulatory requirements.
• Ensure compliance with all relevant laws, regulations, and standards related to patient care transitions.

Quality Improvement:

• Identify opportunities for improvement in the care transition process and participate in quality improvement initiatives.
• Collect and analyze data related to care transitions to identify trends and areas for improvement.

Professional Development:

• Stay current with best practices, industry trends, and advancements in care transition and coordination.
• Participate in ongoing education and professional development opportunities.

Education: Bachelor of Science in Nursing (BSN) is required; Master of Science in Nursing (MSN) is preferred.

Licensure/Certification:

• Current Registered Nurse (RN) license in the state of practice.
• Certification in Case Management (CCM) or Care Coordination (CCCTM) is preferred.

Experience: Minimum of 3-5 years of clinical nursing experience, with at least 2 years in a care coordination or case management role.

Skills and Abilities:

• Strong clinical assessment and critical thinking skills.
• Excellent communication and interpersonal skills.
• Ability to work collaboratively with interdisciplinary teams.
• Strong organizational and time management skills.
• Proficiency in electronic medical records (EMR) and other relevant software.