Care Transition Manager, SW; PRN
About The Position
The Care Transition Manager (Social Worker) in Case Management helps ensure patients transition to appropriate levels of care in a timely and effective manner. The role focuses on care coordination, timely discharge planning, and compassionate, patient-centered care in a multidisciplinary, team-oriented environment. The position is PRN, with flexible scheduling on weekdays and weekends, generally from 8 a.m. to 5 p.m., and requires working two holidays per year. The role is based at Texas Health Plano in Plano, Texas. The hospital is a 366-bed, Magnet-designated facility serving Plano, Frisco, and surrounding communities. It provides a broad range of specialties and advanced services, including emergency medicine, cardiology, behavioral health, pediatrics, intensive care, surgical services, and a Level III NICU.
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) required upon hire.
- CPR (Cardiopulmonary Resuscitation) required upon hire.
Nice To Haves
- Three years of experience in hospital or medical social work preferred.
- Hospital case management experience preferred.
- ACM (Accredited Case Manager), CCM (Certified Case Manager), or other ANCC credential preferred upon hire.
Responsibilities
- 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 (PCP) 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.
- Ensure patients are transitioned to appropriate levels of care in a timely and effective manner.
Benefits
- 401(k).
- Employee Assistance Program (EAP).
- Discount programs.
- Other benefits.
- Flexible daytime hours and ability to choose a schedule.
- Supportive, team-oriented environment with opportunities for growth.
