Care Transition Manager, Social Worker - PRN

#REF!•Dallas, TX

3d•Onsite

About The Position

This role ensures patients are transitioned to appropriate levels of care in a timely and effective manner. The Care Transition Manager, Social Worker will review Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients, identify high-risk patients, and promote discussion to assist in the identification of a primary care physician (PCP). The position involves completing Transition Evaluations within 24 hours of patient identification, beginning discharge planning, interviewing and assessing patients and caregivers, identifying transition needs, and discussing funding of post-transition care.

Requirements

Master’s degree in social work required
One year of experience of discharge planning/care management
LMSW – Licensed Master Social Worker upon hire required or LCSW – Licensed Clinical Social Worker upon hire required
CPR -Cardiopulmonary Resuscitation upon hire required

Nice To Haves

Three years of experience in hospital/medical social work preferred
Hospital Case management preferred
ACM – Accredited Case Manager upon hire preferred or CCM – Certified Case Manager upon hire preferred or Other – ANCC upon hire preferred

Responsibilities

Ensure patients are transitioned to appropriate levels of care in a timely and effective manner
Reviews the Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients
Identify high risk patients whose THRIL score
Promotes discussion and assists in the identification of a primary care physician (PCP) for patients
Completes Transition Evaluations on patients within 24 hours of identification and begins discharge planning
Interviews and assesses patients and caregivers as part of the transition evaluation
Identifies transition needs and discusses funding of post-transition care with patients and caregivers