THPG DISCHARGE NAVIGATOR - Texas Health Southwest at Texas Health Resources – Fort Worth, Texas

THPG DISCHARGE NAVIGATOR - Texas Health Southwest

Bring your passion to Texas Health so we are Better + Together

Position Highlights

• Work location: Texas Health Hospital Medicine 6100 Harris Pkwy, Fort Worth, TX 76132
• Work environment: Office
• Work hours: Full-time, 40 hours weekly, Monday thru Friday, 7:00am - 4:00 pm

Facility: Texas Health Physicians Group (THPG)

What You Will Do:

Responsible for throughput and efficiency for THPG Hospitalist service line:
Works as main facilitator in MDRs by identifying length of stay, expected discharge date, anticipated disposition, avoidable days, and potential denials with the MDR function.
Coordinate multidisciplinary discharge planning (pharmacy, social work, case management, primary care, specialty services) to ensure a smooth transition.
Facilitates care conferences for complex transitions and palliative care needs.
Assess and address social determinants of health that affect discharge (transportation, caregiver support, home safety, financial barriers).
Communicates with Utilization Review nurse to confirm appropriateness of continued stay and proactively identifies patient who no longer meet continued stay criteria.
40%
Coordinates discharge with patient/family and multidisciplinary team:
Verify and optimize medication reconciliation and communicate changes clearly to patients and PCPs.
Schedule and confirm timely post-discharge follow-up appointments (PCP, specialists, rehab, home health) and provide reminders.
Deliver standardized discharge education tailored to literacy and language needs, including red flags and when to seek help.
Provide patient and family coaching on what to expect after discharge and how to manage transitions of care.
Act as a point of contact for patients/families during the first days post-discharge to troubleshoot issues and prevent readmissions.
30%
Performs daily review of Risk of Unplanned Readmission (RUR) scores for assigned patients. 10%
Serves as a resource on payor requirements and barriers. Communicates with payors as needed to coordinate care. 10%
Participates in Joint Commission and other survey readiness activities. 10%

What You Need:

Education
Bachelor's Degree Nursing from an
accredited program RN Req Or

Experience
3 Years Hospital Nursing Experience Req
1 Year Care Transitions Management, Skilled nursing facility and/or home health experience Pref

Licenses and Certifications
RN - Registered Nurse Completion of RN from an
accredited program. Must be
licensed in the state of Texas and
be in good standing. Upon Hire Req Or
BCLS - Basic Cardiac Life Support Upon Hire Req

Skills
Great communication skills
Ability to show empathy
Practiced in and knowledge of Medicare Advantage and Commercial programs and benefits preferred.
Chronic disease management of diverse patient populations and/or experience in health coaching.
Excellent time management skills with ability to prioritize tasks effectively and efficiently.

Education
Bachelor's Degree Nursing from an
accredited program RN Req Or

Experience
3 Years Hospital Nursing Experience Req
1 Year Care Transitions Management, Skilled nursing facility and/or home health experience Pref

Licenses and Certifications
RN - Registered Nurse Completion of RN from an
accredited program. Must be
licensed in the state of Texas and
be in good standing. Upon Hire Req Or
BCLS - Basic Cardiac Life Support Upon Hire Req

Skills
Great communication skills
Ability to show empathy
Practiced in and knowledge of Medicare Advantage and Commercial programs and benefits preferred.
Chronic disease management of diverse patient populations and/or experience in health coaching.
Excellent time management skills with ability to prioritize tasks effectively and efficiently.

Supervision
Individual Contributor

ADA Requirements
Extreme Heat 1-33%
Extreme Cold 1-33%
Extreme Swings in Temperature 1-33%
Extreme Noise 1-33%
Working Outdoors 1-33%
Working Indoors 67% or more
Mechanical Hazards 1-33%
Electrical Hazards 1-33%
Explosive Hazards 1-33%
Fume/Odor Hazards 1-33%
Dust/Mites Hazards 1-33%
Chemical Hazards 1-33%
Toxic Waste Hazards 1-33%
Radiation Hazards 1-33%
Wet Hazards 1-33%
Heights 1-33%
Other Conditions 1-33%

Physical Demands
Sedentary

Travel Requirements
Local 5% May be asked to travel to different hospitals periodically.

Primary Location: Fort Worth
Job: RN/Registered Nurse
Organization: Texas Health Physicians Group 9250 Amberton Parkway TX 75243
Shift: Day Job
Employee Status: Regular
Job Type: Standard
Schedule: Full-time