Care Transition Manager, Social Worker - PRN, Days
About The Position
The Care Transition Manager Social Worker works in the Care Management department at Texas Health Allen. The role helps ensure patients transition to appropriate levels of care in a timely and effective manner. The social worker reviews readmission risk indicators, identifies high-risk patients, supports identification of a primary care physician, completes transition evaluations, assesses patients and caregivers, identifies transition needs, and discusses funding for post-transition care. The role collaborates with physicians, staff, patients, and families on discharge needs and participates in daily interdepartmental rounds to support agreement on discharge plans. This is a PRN position with hours listed as 8:30 a.m. to 4:30 p.m., including 2–4 weekend shifts and additional weekday shifts to cover full-time staff PTO.
Requirements
- Master’s degree in social work.
- One year of experience in discharge planning or care management.
- LMSW or LCSW license required upon hire.
- CPR certification required upon hire.
Nice To Haves
- Three years of experience in hospital or medical social work.
- Hospital case management experience.
- ACM, CCM, or another ANCC credential upon hire.
Responsibilities
- Collaborate with physicians, staff, patients, and families to determine discharge needs.
- Participate in daily interdepartmental rounds with the charge RN, physicians, and care transition managers to support open communication and agreement on discharge plans.
- Review Texas Health Readmission Indicator List (THRIL) scores daily for assigned patients.
- Identify high-risk patients based on their THRIL scores.
- Promote discussion and assist in identifying a primary care physician for patients.
- Complete transition evaluations within 24 hours of identifying patients and begin discharge planning.
- Interview and assess patients and caregivers as part of the transition evaluation.
- Identify transition needs and discuss funding for post-transition care with patients and caregivers.
Benefits
- 401(k)
- PTO
- Medical benefits
- Dental benefits
- Paid parental leave
- Flexible spending
- Tuition reimbursement
- Student loan forgiveness
- Other benefits
