Care Transition Manager, Social Worker

Texas Health Resources•Fort Worth, TX

3d•Onsite

About The Position

The Care Transition Manager Social Worker plays a crucial role in supporting patients within a Magnet-designated, full-service hospital. This rewarding career offers family-friendly hours and involves comprehensive discharge planning and care management for high-risk patient populations. The role focuses on improving patient outcomes and ensuring safe transitions to appropriate levels of care, coordinating with patients, families, and multidisciplinary teams.

Requirements

Master's Degree Social Work required
LMSW - Licensed Master Social Worker Upon Hire required
LCSW - Licensed Clinical Social Worker Upon Hire required
CPR - Cardiopulmonary Resuscitation Upon Hire required

Nice To Haves

3 years in hospital/ medical social work preferred
1 year discharge planning/care management preferred
ACM - Accredited Case Manager Upon Hire preferred
CCM - Certified Case Manager Upon Hire preferred
Other ANCC Upon Hire preferred

Responsibilities

Completes Transition Evaluations and collects Social Determinants of Health (SDOH) data on patients within 48 hours of identification and begins discharge planning.
Assesses and interviews patients and caregivers as part of this evaluation and as needed.
Reviews the Risk of Unplanned Readmission (RUR) scores daily for all assigned patients.
Assists in the identification of a primary care physician (PCP) for patients without a PCP and attempts to schedule follow up appointments with either a PCP, specialist, clinic, physician, or other transitional care visit prior to discharge.
Identifies transition needs and discusses funding of post-transition care with patients and caregivers.
Participates in multidisciplinary rounds (MDR’s) to help identify current length of stay (LOS), expected discharge date, anticipated discharge disposition, barriers to discharge, avoidable days, and potential denials.
Coordinates/facilitates patient care progression throughout the continuum with the objective of enhancing quality clinical outcomes and safe discharge planning to the appropriate levels of care for high-risk patient populations.
Coordinates with patients and families to manage chronic conditions and ensures appropriate post-discharge clinical follow up.