Care Transition Manager Social Worker PRN Position

3 weeks ago

Fort Worth, Texas, United States Texas Health Resources Full time

Care Transition Manager Social Worker Job Summary

We are seeking a skilled Care Transition Manager Social Worker to join our team at Texas Health Resources. As a Care Transition Manager Social Worker, you will play a critical role in ensuring patients are transitioned to appropriate levels of care in a timely and effective manner.

Key Responsibilities:

  • Review the Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients and collaborate with the interdisciplinary team to identify high-risk patients whose THRIL score may not have indicated appropriately.
  • Promote discussion and assist in the identification of a primary care physician (PCP) for patients without a PCP.
  • 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 and as needed.
  • Identify transition needs and discuss funding of post-transition care with patients and caregivers.
  • Identify Geometric Mean Length of Stay (GMLOS) and update the Anticipated Date of Discharge (ADOD) as necessary while considering excess days risk.
  • Identify community resources and service needs and facilitate appropriate referrals as needed.
  • Communicate with the multidisciplinary team (physicians, nursing, therapy), patient, family, and post-acute care stakeholders in order to coordinate care.
  • Educate patients, caregivers, and the multidisciplinary team regarding available post-acute care services and needs.
  • Facilitate care conferences for complex transitions, placement, and palliative care needs.
  • Proactively identify patients who no longer meet continued stay criteria and communicate with the physician team.
  • Attempt to schedule PCP, specialist, or clinic follow-up appointments for patients.

Requirements:

  • Master's Degree in Social Work (MSW) or related field.
  • 3 years of experience in hospital/medical social work, preferably in a care transition setting.
  • 1 year of experience in discharge planning/care management, preferably in a care transition setting.
  • Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW) upon hire.
  • CPR certification upon hire.
  • Accredited Case Manager (ACM) or Certified Case Manager (CCM) certification, or other ANCC certification, preferred.
  • Working knowledge of medical necessity criteria and Microsoft Office (Word, Excel).
  • Excellent customer service, psychosocial, and crisis intervention skills.
  • Ability to engage in complex clinical decision-making, critical thinking, analysis, and conflict resolution skills.
  • Strong oral and written communication skills.
  • Strong commitment to interdisciplinary collaboration.
  • Flexible scheduling as necessary.
  • Ability to prioritize and meet deadlines.

What We Offer:

  • Competitive salary and benefits package.
  • Opportunities for professional growth and development.
  • A supportive, team-oriented work environment.
  • Discounts in the cafeteria and free parking.

How to Apply:

Please submit your resume and cover letter to [insert contact information]. We are an equal opportunity employer and welcome applications from diverse candidates.

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