Care Transition Manager, Social Worker - PRN, Days

Texas Health Resources•Plano, TX

31d•Onsite

About The Position

Care Transition Manager SW – Care Management Bring your passion to Texas Health so we are Better + Together! Work location: Texas Health Plano, 6200 West Parker Road, Plano TX 75093 Work hours: PRN; Days, Weekdays and weekends (3 shift min. per schedule - which runs a month. 2 holidays per year) Care Management Highlights: · Flexible daytime hours · Opportunity to work with a diverse group of highly educated professionals · Care coordination with focus on timely discharges · Ability to pick your own schedule · Multidisciplinary team focus · Team oriented with focus on providing compassionate patient centered care · Evidence based practice Here’s What You Need · Master’s degree in social work required · Three years of experience in hospital/medical social work preferred · One year of experience of discharge planning/care management · Hospital Case management preferred · LMSW – Licensed Master Social Worker upon hire required or LCSW – Licensed Clinical Social Worker upon hire required and CPR -Cardiopulmonary Resuscitation upon hire required and ACM – Accredited Case Manager upon hire preferred or CCM – Certified Case Manager upon hire preferred or Other – ANCC upon hire preferred What You Will Do 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 Additional perks of being a Texas Health Employee: · Benefits include 401k, Employee Assistance Program (EAP), Discount Programs, as well as other benefits. · Delivery of high-quality patient care · Strong Unit Based Council (UBC). · A supportive, team environment with outstanding opportunities for growth. Learn more about our culture, benefits, and recent awards! Entity Highlights: Texas Health Plano Highlights: Texas Health Presbyterian Hospital Plano is a 366-bed, Magnet-designated hospital and recognized clinical leader, providing technologically advanced care to Plano, Frisco and surrounding communities since 1991. This full-service facility features a full range of specialties including emergency medicine, cardiology, adult and adolescent behavioral health, pediatrics, an adult intensive care unit, state of the art and technologically advanced surgical services and Level III NICU. Texas Health Plano has more than 1,600 employees and over 1,360 physicians on its medical staff in more than 65 specialties. The hospital is an Advanced Level III Trauma Facility, accredited Chest Pain Center by The Joint Commission, named “Best Place to Have a Baby” in Collin County and a Gold-Level Mother Friendly business. Texas Health Plano is the recipient of the Disease Specific Care Certifications from the Joint Commission in Chest Pain, Joint Replacement – Hip and Joint Replacement – Knee and an Advanced Certification as a Primary Stroke Center. We invite you to join us in furthering your career and our accomplishments and philosophy of excellence. If you’re ready to join us in our mission to improve the health of our community, then let’s show the world how we’re even better together! Do you still have questions or concerns? Email your questions to: [email protected] #LI-AW1

Requirements

Master’s degree in social work required
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
One year of experience of discharge planning/care management
Hospital Case management preferred
ACM – Accredited Case Manager upon hire preferred
CCM – Certified Case Manager upon hire preferred
Other – ANCC upon hire preferred

Responsibilities

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