Care Transition Manager, SW; PRN

Texas Health Resources•Plano, TX

2d•Onsite

About The Position

The Care Transition Manager is a social worker in Case Management at Texas Health Presbyterian Hospital Plano. This PRN role supports timely, effective transitions to appropriate levels of care through patient assessment, care coordination, and discharge planning. The position works with patients, caregivers, and a multidisciplinary team to identify transition needs and discuss funding for post-transition care. The schedule is flexible, with daytime hours Monday through Friday and weekends, typically 8 a.m. to 5 p.m. Employees are required to work two holidays per year. The position is based at Texas Health Plano in Plano, Texas.

Requirements

Master’s degree in social work.
One year of experience in discharge planning or care management.
LMSW (Licensed Master Social Worker) or LCSW (Licensed Clinical Social Worker) upon hire.
CPR (Cardiopulmonary Resuscitation) upon hire.

Nice To Haves

Three years of experience in hospital or medical social work.
Hospital case management experience.
ACM (Accredited Case Manager) upon hire.
CCM (Certified Case Manager) upon hire.
Other – ANCC upon hire.

Responsibilities

Ensure patients are transitioned to appropriate levels of care in a timely and effective manner.
Review the Texas Health Readmission Indicator List (THRIL) scores daily for assigned patients.
Identify high-risk patients based on THRIL scores.
Promote discussion and assist in identifying a primary care physician for patients.
Complete Transition Evaluations within 24 hours of identification 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.