Care Transition Manager – Discharge Planning Social Worker

Texas Health Resources; Fort Worth (TX); On-site; USD 65,000 - 90,000; Part time

Benefits offered by this job

401k

Cafeteria discounts

Growth opportunities

Job summary

Texas Health Resources seeks a Care Transition Manager Social Worker (LMSW/LCSW) for PRN hours at the Fort Worth location. Requires MSW and licensure upon hire, with prior hospital social work and discharge planning experience preferred.

Expect cross‑functional teamwork, care coordination, and timely patient transitions within a Magnet-designated hospital. The role emphasizes complex clinical decision-making, strong communication, and collaboration with interdisciplinary teams to optimize

Qualifications

• Master's Degree in Social Work required; LMSW or LCSW upon hire.
• 3 years hospital/medical social work experience preferred.
• 1 year discharge planning/care management preferred.
• CPR - Upon Hire Required; ACM/CCM preferred.

Responsibilities

• Identify community resources and facilitate appropriate referrals.
• Ensure patients transition to appropriate levels of care in a timely and effective manner.
• Review THRIL scores daily and collaborate with the inter-disciplinary team.
• Promote discussion to identify a PCP for patients without one.
• Complete Transition Evaluations within 24 hours of identification and begin discharge planning.

Skills

Outlook

MS Office

Customer service

Clinical decision-making

Discharge planning

Communication skills

Interdisciplinary collaboration

Critical thinking

Crisis intervention

Time management

Community resource referrals

Education

Masters in Social Work (MSW)

LMSW or LCSW Upon Hire

Tools

Microsoft Outlook

Microsoft Office (Word, Excel)

Job description

Texas Health Resources seeks a Care Transition Manager Social Worker (LMSW/LCSW) for PRN hours at the Fort Worth location. Requires MSW and licensure upon hire, with prior hospital social work and discharge planning experience preferred.

Expect cross‑functional teamwork, care coordination, and timely patient transitions within a Magnet-designated hospital. The role emphasizes complex clinical decision-making, strong communication, and collaboration with interdisciplinary teams to optimize