Care Transition Manager: Social Work (Flexible Schedule)

Texas Health Resources; Plano (TX); Vor Ort; USD 60.000 - 90.000; Vollzeit

Benefits dieser Stelle

401k

Employee Assistance Program (EAP)

Discount Programs

Zusammenfassung

Texas Health Resources in Plano is seeking a Care Transition Manager SW to coordinate transitions from hospital to appropriate care levels. This role emphasizes timely discharges, THRIL score monitoring, and collaboration with a multidisciplinary team to ensure patient-centered care.

The position requires a Master’s in Social Work, state licensure (LMSW/LCSW), CPR, and preferred ACM/CCM or ANCC credentials, with flexible PRN daytime hours and potential weekend coverage.

Qualifikationen

• Master’s degree in social work required.
• Three years of hospital/medical social work experience preferred.
• One year of discharge planning/care management experience.
• LMSW or LCSW licensure required on hire; CPR required on hire; ACM/CCM certification preferred or ANCC preferred.

Aufgaben

• Ensure patients are transitioned to appropriate levels of care in a timely and effective manner.
• Review Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients.
• Identify high risk patients whose THRIL score is elevated.
• Promote discussion and assist in the identification of a primary care physician (PCP) for patients.
• Complete Transition Evaluations on patients within 24 hours of identification and begin discharge planning.
• Interview and assess patients and caregivers as part of the transition evaluation.
• Identify transition needs and discuss funding of post-transition care with patients and caregivers.

Kenntnisse

Hospital/medical social work

Discharge planning / care management

Ausbildung

Master’s degree in social work

LMSW or LCSW licensure

CPR certification

ACM or CCM certification preferred

ANCC certification preferred

Jobbeschreibung

Texas Health Resources in Plano is seeking a Care Transition Manager SW to coordinate transitions from hospital to appropriate care levels. This role emphasizes timely discharges, THRIL score monitoring, and collaboration with a multidisciplinary team to ensure patient-centered care.

The position requires a Master’s in Social Work, state licensure (LMSW/LCSW), CPR, and preferred ACM/CCM or ANCC credentials, with flexible PRN daytime hours and potential weekend coverage.