Care Transition Social Worker: Discharge Planning & Care Coordination

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

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.