Care Transitions Nurse - RN

Care Transitions Nurse - RN

Presbyterian Village North, DALLAS, Texas, United States – Full‑Time

Join Our Team! Presbyterian Village North is immediately hiring for a Care Transitions Nurse - RN in our Skilled Nursing Department.

Shift: Monday – Friday, 8:00 a.m. – 5:00 p.m. + on‑call rotation every 5th week (Monday thru Sunday – all shifts) $250.00 on‑call payment.

The Care Transitions Nurse is responsible for reviewing qualified hospital referrals for admission, assessing patient needs at the time of referral, and continuously communicating with the admissions team for the patient’s plan of care. The Care Transitions Nurse is also responsible for communicating with Clinical Liaisons and the Admissions Coordinator on patient referrals.

• Maintain admissions and re‑admissions of residents including physician orders and admission assessments.
• Provides clinical review and response of all hospital referrals within 30 minutes or less.
• Prioritizes incoming referrals on all clinical reviews for timely and quick response to the Admissions Coordinator and Clinical Liaison based on discharge plan.
• Reviews MAR/TAR and communicates cost outliers and special needs with nursing before approving admission.
• Communicates known clinical needs to the nursing team to prepare for resident admission.
• Completes preadmission screening in EHR outlining patient care on approved admissions before the admission.
• Initiates interim care plan in EHR.
• Meets with new residents after admission to determine needs are met.
• Communicates with the attending physician and/or NP on specified needs for new admissions.
• Assists with admission, when necessary, as instructed by the Healthcare Administrator or Director of Nursing.
• Assists with the discharge planning process.
• Coordinates and makes post discharge calls.
• Tracks rehospitalizations in the EHR.
• Maintains current knowledge of the community’s clinical capabilities and staffing levels.
• Adheres to professional code of ethics.
• Performs other tasks as assigned by the Director of Nursing.
• Staffing on‑call rotation (every 5th week – Mon‑Sun, all shifts) + on‑call pay.

• Current Registered Nursing license in good standing.
• Two years of admissions experience in a Long Term Care setting preferred.

Salary information is not provided.