Care Transition Manager Registered Nurse (RN) PRN Saturday and Sunday - 1st shift - Flexible Scheduling
Texas Health Resources
 Cleburne, TX

Texas Health Resources seeks to hire a Care Transition Manager Registered Nurse to join the Care Management Team.

The address is Texas Health Cleburne 201 Walls Drive, Cleburne, TX 76031.

Salary: Min $35.69 – Max $50.46, based on relevant work experience.


  • PRN: Saturday and Sunday, 1st shift (Flexible scheduling – 8 hour shifts)

Two weekends per month. Weekdays based on the departments need.

As a Care Transition Manager Registered Nurse with Texas Health Resources, this position is responsible for ensuring patients are timely and effectively transitioned to appropriate levels of care from the Emergency Room.

The essential duties of this position are:

  • 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. 60%
  • 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.
  • Ensures transition plan and post-acute management plan consistency across care settings.
  • Perform other duties as assigned.


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 Acute care hospital discharge preferred.
  • RN - Registered Nurse required upon hire.
  • CPR - Cardiopulmonary Resuscitation required upon hire.
  • ACM - Accredited Case Manager or CCM - Certified Case Manager preferred upon hire


  • 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


Texas Health Resources is one of the largest faith-based, nonprofit health care delivery systems in the United States and the largest in North Texas in terms of patients served.

Texas Health has 25 acute-care and short-stay hospitals that are owned, operated, joint-ventured or affiliated with the system. It has more than 3,800 licensed beds, more than 21,100 employees of fully-owned/operated facilities plus 1,400 employees of consolidated joint ventures and counts more than 5,500 physicians with active staff privileges at its hospitals.

At Texas Health, we strive to create an atmosphere of respect, integrity, compassion and excellence for all who come in contact with us, be they patients or our employees. We are committed to diversity in our workforce, and our mission to serve spreads across ethnic, cultural, economic and generational boundaries. We invite you to join us in furthering your career through 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