Texas Health Resources RN-Care Transition Nurse-Full Time-Day Shift in Fort Worth, Texas


Texas Health Fort Worth has an opportunity for a Care Transition Nurse working full time, Saturday, Sunday and Monday, 7a (0700) to 7:30p (1930). The role will be working with the patient, family, provider and facilities assisting with patient discharge.

At Texas Health we are 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.

The successful candidate will possess the following qualifications:

Required minimum education:

Graduate of a NLN (National League of Nursing) or CCNE (Commission on Collegiate Nursing Education) accredited nursing programs.

BSN is required.

Required minimum experience:

Minimum of five (5) years clinical experience as staff nurse in an acute care hospital (required).

Minimum of two (2) years acute care hospital discharge planning/care management(preferred)

CPR certification within 30 days of hire and maintained thereafter.

ACM, ANCC or CCM certification (preferred)

Required 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

Psychosocial and crisis intervention skills.

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


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

• Reviews Readmission Risk Predictor (RRP) 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.

• 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; facilitates appropriate referrals as needed (acute and non-acute).

• Communicates with payors as needed.

• Assigns patients to appropriate transition program(s) (i.e. Healthways, NTSP, THPG or based on payor preferences) and provides support as needed.

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

• Escalates issues to appropriate level of CTM leadership and coordinates mitigation activities as needed.

• 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.

• 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).

• Ensures transition plan and post-acute management plan consistency across care settings.

• 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.

• 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.

Entity Information

Texas Health Harris Methodist Hospital Fort Worth is a 726-bed, Magnet-designated regional referral center that has served the residents of Tarrant County and surroundings communities since 1930. Hospital services include cardiovascular care, high-risk obstetrics, gynecology, orthopedics and sports medicine, neonatal intensive care, and trauma/emergency medicine. In early 2014, Texas Health Fort Worth will be opening a new 75,000 square foot Emergency Services Center, one of the largest in the region. Texas Health Fort Worth has more than 4,000 employees, 200 volunteers and nearly 1,000 physicians on its medical staff. Texas Health Fort Worth recently received national recognition for its oncology program and was named “Best Place to Have a Baby” in Tarrant County. The hospital is also a designated Cycle III Chest Pain Center by the Society of Chest Pain Centers We invite you to join us in furthering your career and our accomplishments and philosophy of excellence.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.