Care Transition Manager - Social Work | Growth & Impact

Texas Health Resources; Texas; On-site; USD 70,000 - 110,000; Full time

Benefits offered by this job

401(k)

PTO

Medical insurance

Dental insurance

Paid Parental Leave

Flex Spending Account

Tuition Reimbursement

Student Loan Forgiveness

Growth opportunities

Job summary

Texas Health Resources in Dallas, TX, is seeking a Care Transition Manager Social Worker (SW) to ensure timely, safe transitions of patients to appropriate levels of care. The role requires a Master’s in Social Work, active licensure, and experience in hospital-based social work and discharge planning.

You will collaborate with care teams, review THRIL scores, identify high‑risk patients, coordinate primary care access, and complete transition evaluations within 24 hours.

Qualifications

• Master’s degree in social work is required.
• Three years of hospital/medical social work experience preferred.
• One year of discharge planning experience required.
• LMSW and LCSW licenses required upon hire.
• CPR certification required upon hire.
• ACM and CCM certifications preferred.
• ANCC certification preferred.

Responsibilities

• Ensure patients are transitioned to appropriate levels of care in a timely and effective manner.
• Review THRIL scores daily for all assigned patients.
• Identify high‑risk patients whose THRIL score indicates elevated risk.
• Promote discussion and assist in identifying a PCP for patients.
• Complete Transition Evaluations 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.

Skills

Communication skills

Assessment and care coordination

Discharge planning

Interdisciplinary teamwork

Education

Master’s degree in social work

LMSW – Licensed Master Social Worker

LCSW – Licensed Clinical Social Worker

Job description

Texas Health Resources in Dallas, TX, is seeking a Care Transition Manager Social Worker (SW) to ensure timely, safe transitions of patients to appropriate levels of care. The role requires a Master’s in Social Work, active licensure, and experience in hospital-based social work and discharge planning.

You will collaborate with care teams, review THRIL scores, identify high‑risk patients, coordinate primary care access, and complete transition evaluations within 24 hours.