Care Transition Manager Social Worker PRN Position

6 days ago

Fort Worth, Texas, United States Texas Health Resources Full time
Care Transition Manager Social Worker Job Description

We are seeking a skilled Care Transition Manager Social Worker to join our team at Texas Health Resources. This is a PRN position, requiring flexibility and adaptability to meet the needs of our patients and staff.

Key Responsibilities:

  • Manage care transitions for patients, ensuring a smooth and effective transition to appropriate levels of care.
  • Collaborate with the interdisciplinary team to identify high-risk patients and develop strategies to improve care outcomes.
  • Promote discussion and assist in identifying primary care physicians for patients without a PCP.
  • Complete Transition Evaluations and begin discharge planning within 24 hours of identification.
  • Identify transition needs and discuss funding of post-transition care with patients and caregivers.
  • Communicate with the multidisciplinary team, patient, family, and post-acute care stakeholders to coordinate care.
  • Facilitate care conferences for complex transitions, placement, and palliative care needs.
  • Ensure compliance with documentation guidelines and regulatory agency requirements.

Requirements:

  • Master's Degree in Social Work.
  • 3 years' experience in hospital/medical social work (preferred).
  • 1 year discharge planning/care management experience (preferred).
  • Working knowledge of medical necessity criteria (preferred).
  • Knowledge of Microsoft Outlook and Office (Word, Excel).
  • Ability to engage in complex clinical decision-making, critical thinking, analysis, and conflict resolution skills.

Additional Perks:

  • Flexible scheduling as necessary.
  • Opportunity to work in a Magnet status, Level II Trauma facility, Stroke & Chest pain certified, Hip & Knee Orthopedics certified environment.

We are an Equal Opportunity Employer and do not discriminate against any employees or applicants for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state, or local protected class.

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