Care Transitions Manager – Social Work

Texas Health Resources; Dallas (TX); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

401k

Paid PTO

Medical insurance

Dental insurance

Paid Parental Leave

Tuition reimbursement

Student Loan Repayment

Flex spending

Job summary

Texas Health Resources invites an experienced Social Worker to join the Care Transition team in Dallas. This PRN role supports care management and transition planning for hospital patients, coordinating discharge needs and care levels with physicians, patients, and families.

You will assess patients, coordinate with care teams, and ensure timely transitions while maintaining high-quality patient care and adherence to hospital standards.

Qualifications

• Master's degree in social work is required.
• Three years of hospital/medical social work experience preferred.
• One year of discharge planning/care management experience required.
• LMSW/LCSW upon hire is required; CPR required; ACM/CCM preferred or ANCC preferred.

Responsibilities

• Ensure patients are transitioned to appropriate levels of care in a timely and effective manner.
• Review THRIL scores daily for all assigned patients to identify high risk cases.
• Promote discussion and help identify a PCP for patients.
• Complete Transition Evaluations within 24 hours and begin discharge planning.
• Interview and assess patients and caregivers as part of transition evaluation.
• Identify transition needs and discuss funding of post-transition care with patients and caregivers.

Skills

Discharge planning

Care management

Hospital case management

CPR certification

Patient care coordination

Education

Master's degree in Social Work

LMSW or LCSW required upon hire

ACM or CCM preferred

ANCC preferred

Job description

Texas Health Resources invites an experienced Social Worker to join the Care Transition team in Dallas. This PRN role supports care management and transition planning for hospital patients, coordinating discharge needs and care levels with physicians, patients, and families.

You will assess patients, coordinate with care teams, and ensure timely transitions while maintaining high-quality patient care and adherence to hospital standards.