Care Transition Manager Social Worker PRN

Naswtx; Cleburne (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 in Cleburne, TX is seeking a Care Transition Manager Social Worker (MSW) to support patient transitions to appropriate levels of care. The role requires hospital social work experience, licensure, and strong discharge planning skills.

Responsibilities include coordinating post‑acute care, collaborating with the interdisciplinary team, and ensuring timely transition evaluations to optimize patient outcomes. PRN days, with occasional weekends.

Qualifications

• Master's Degree in Social Work required.
• LMSW or LCSW licensure upon hire required.
• CPR certification upon hire required.
• ACM/CCM preferred.
• Strong communication and teamwork abilities.

Responsibilities

• Identify transition needs and coordinate discharge planning.
• Review THRIL scores daily and collaborate with the care team.
• Facilitate referrals to appropriate post‑acute care options.
• Engage in psychosocial assessment and crisis intervention as needed.
• Promote coordination with PCPs and community resources.

Skills

Discharge planning

Interdisciplinary collaboration

Clinical decision‑making

Crisis intervention

Communication skills

Education

Master's Degree in Social Work

LMSW or LCSW licensure required

Tools

Microsoft Outlook

Microsoft Word

Excel

Job description

# Care Transition Manager Social Worker PRNTexas Health ResourcesTexas, TXShareCare Transition Manager Social Worker LMSW/LCSW Bring your passion to Texas Health so we are Better + Together Work location: Texas Health Cleburne 201 Walls Dr. Cleburne, TX 76033 Work hours: PRN Days - Between 8:00 am - 5p to cover sick/pto time. Occasional weekends required. Department highlights: · Robust Unit Based Council (UBC) and engaged leadership team · The Care Transition team ensures that patients are transitioned to appropriate level of care in a timely and effective manner. Provides education, care and resources to patients across various specialties to identify transition needs and discuss post- acute care options · Manageable Case Load · Team that works together to ensure work life balance for all 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. Do you still have questions or concerns? Feel free to email your questions to [e-mail]