Care Transition Manager Social Worker LMSW/LCSW PRN

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

26009294

Care Transition Manager Social Worker LMSW/LCSW

PRN

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

• Work location: Texas Health Ft. Worth, 1301 Pennsylvania Avenue, Ft. Worth, TX 76104
• Care Transition Management department
• Work hours: PRN, mainly weekdays between 7:30AM-5:00PM, on an as needed basis, Weekends are optional; During training, hours will vary between 7:30AM-5:30PM
• (***Does Require 5-weeks of training Monday to Friday***)

Care Transition Management Department Highlights

• Supporting the 815-bed, Magnet-designated, full-service hospital that has served the Ft. Worth and surrounding community since 1930

Care Transition is a rewarding career with family-friendly hours

Here’s What You Need

• Master's Degree Social Work Required (Individuals hired as a CTSW prior to May 11, 2017, will be grandfathered to the CTSW position with BSW, at the entity they were employed at on May 11, 2017)
• 3 Years’ experience in hospital/medical social work Preferred
• 1 Year discharge planning/care management Preferred
• LMSW - Licensed Master Social Worker Upon Hire Required Or

LCSW - Licensed Clinical Social Worker Upon Hire Required

• CPR - Cardiopulmonary Resuscitation Upon Hire Required
• ACM - Accredited Case Manager Upon Hire Preferred
• CCM - Certified Case Manager Upon Hire Preferred Or

Other ANCC Upon Hire Preferred

What You Will Do

• Working knowledge of medical necessity criteria preferred
• Knowledge of Microsoft Outlook and Office (Word, Excel)
• Customer service skills
• Ability to engage in complex clinical decision-making and discharge planning
• Strong oral and written communication skills
• Strong commitment to interdisciplinary collaboration
• Critical thinking, analysis and conflict resolution skills
• Psychosocial and crisis intervention skills
• Ability to prioritize and meet deadlines
• Identify community resources and service needs and facilitate appropriate referrals as needed.
• Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner.
• Reviews the Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients and collaborates with the interdisciplinary team to identify high risk patients whose THRIL score may not have indicated appropriately.
• Promotes discussion and assists in the identification of a primary care physician (PCP) for patients without a PCP
• Completes Transition Evaluations on patients within 24 hours of identification and begins discharge planning

Additional Perks Of Being a Texas Health Social Worker

• Benefits include 401k, discounts in the cafeteria.
• A supportive, team environment with outstanding opportunities for growth.
• Explore our Texas Health careers site for info like Benefits, Job Listings by Category, recent Awards we’ve won and more.