Care Transition Manager, SW; PRN

Texas Health Resources; Texas; On-site; USD 65,000 - 85,000; Part time

Benefits offered by this job

401k

Employee Assistance Program (EAP)

Discount Programs

Job summary

Texas Health Resources is seeking a Care Transition Manager SW (Social Worker) to support case management at Plano location. This role focuses on timely discharges, care coordination, and evidence-based practices within a multidisciplinary team.

The ideal candidate holds a Master’s in Social Work and LMSW/LCSW licensure, with prior hospital social work and discharge planning experience. PRN, flexible daytime schedule with two holidays per year.

Qualifications

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

Responsibilities

• Ensure patients transition to appropriate levels of care in a timely, effective manner.
• Review THRIL scores daily for assigned patients.
• Identify high-risk patients and coordinate with PCPs.
• Complete Transition Evaluations within 24 hours and begin discharge planning.
• Interview patients and caregivers during transition evaluations.
• Discuss post-transition funding needs with patients and caregivers.

Skills

Discharge planning

Care coordination

Hospital social work

CPR certification

Education

Master’s degree in social work

LMSW or LCSW licensure

Job description

Care Transition Manager SW (Social Worker) – Case Management Bring your passion to Texas Health so we are Better + Together!

Work location: Texas Health Plano, 6200 West Parker Road, Plano TX 75093

Work hours: PRN - Flexible, M-F and weekends. 8a-5p. Two holidays per year required

Care Management Highlights:

• Flexible daytime hours
• Opportunity to work with a diverse group of highly educated professionals
• Care coordination with focus on timely discharges
• Ability to pick your own schedule
• Multidisciplinary team focus
• Team oriented with focus on providing compassionate patient centered care
• Evidence based practice

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 of discharge planning/care management
• Hospital Case management preferred
• LMSW – Licensed Master Social Worker upon hire required or LCSW – Licensed Clinical Social Worker upon hire required and CPR -Cardiopulmonary Resuscitation upon hire required and ACM – Accredited Case Manager upon hire preferred or CCM – Certified Case Manager upon hire preferred or Other – ANCC upon hire preferred

What You Will Do

• Ensure 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
• Identify high risk patients whose THRIL score
• Promotes discussion and assists in the identification of a primary care physician (PCP) for patients
• Completes Transition Evaluations on patients within 24 hours of identification and begins discharge planning
• Interviews and assesses patients and caregivers as part of the transition evaluation
• Identifies transition needs and discusses funding of post‑transition care with patients and caregivers

Additional perks of being a Texas Health Social Worker

• Benefits include 401k, Employee Assistance Program (EAP), Discount Programs, as well as other benefits.
• Delivery of high-quality patient care
• Strong Unit Based Council (UBC).
• A supportive, team environment with outstanding opportunities for growth.

Entity Highlights

Texas Health Presbyterian Hospital Plano is a 366-bed, Magnet-designated hospital and recognized clinical leader, providing technologically advanced care to Plano, Frisco and surrounding communities since 1991. This full-service facility features a full range of specialties including emergency medicine, cardiology, adult and adolescent behavioral health, pediatrics, an adult intensive care unit, state of the art and technologically advanced surgical services and a Level III NICU. Texas Health Plano has more than 1,600 employees and over 1,360 physicians on its medical staff in more than 65 specialties. The hospital is an Advanced Level III Trauma Facility, accredited Chest Pain Center by The Joint Commission, named “Best Place to Have a Baby” in Collin County and a Gold-Level Mother Friendly business. Texas Health Plano is the recipient of the Disease Specific Care Certifications from the Joint Commission in Chest Pain, Joint Replacement – Hip and Joint Replacement – Knee and an Advanced Certification as a Primary Stroke Center. We invite you to join us in furthering your career and our accomplishments and philosophy of excellence.

Do you still have questions or concerns? Feel free to email your questions to [e-mail]. #LI-AW1