Care Transition Manager, Social Worker - PRN

Texas Health Resources, Inc.; Texas; In loco; USD 70.000 - 110.000; Tempo pieno

Vantaggi offerti da questo lavoro

401(k)

PTO

Medical insurance

Dental insurance

Paid Parental Leave

Flex Spending Account

Tuition Reimbursement

Student Loan Forgiveness

Growth opportunities

Descrizione del lavoro

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.

Competenze

• 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.

Mansioni

• 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.

Conoscenze

Communication skills

Assessment and care coordination

Discharge planning

Interdisciplinary teamwork

Formazione

Master’s degree in social work

LMSW – Licensed Master Social Worker

LCSW – Licensed Clinical Social Worker

Descrizione del lavoro

Care Transition Manager Social Worker (SW)

Location: Texas Health Dallas, 8200 Walnut Hill Lane, Dallas, TX 75231. Work hours: PRN; Weekends.

Care Management Highlights

• Engaged leadership team
• Manageable case load
• Team that works together to ensure work/life balance for all

Here’s What You Need

• Master’s degree in social work required
• Three years of experience in hospital/medical social work preferred
• One year of experience in discharge planning/care management
• Hospital case management preferred
• LMSW – Licensed Master Social Worker upon hire required
• 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
• ANCC upon hire preferred

What You Will Do

• Ensure patients are transitioned to appropriate levels of care in a timely and effective manner
• Review the Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients
• Identify high‑risk patients whose THRIL score indicates elevated risk
• Promote discussion and assist in identifying 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

Additional perks of being a Texas Health Employee

• Benefits include 401(k), PTO, Medical, Dental, Paid Parental Leave, Flex Spending, Tuition Reimbursement, Student Loan Forgiveness and other benefits
• Delivery of high quality patient care through nursing education, nursing research, and innovations in nursing practice
• Strong Unit Based Council (UBC)
• Supportive, team environment with outstanding opportunities for growth