Care Transition Manager, Social Worker - PRN, Days
About The Position
The Care Transition Manager (CTM) is responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner. This role involves collaborating with physicians, staff, patients, and families to determine discharge needs, ensuring open communication through daily interdepartmental rounds, and providing supportive experienced coworkers. The CTM will review Texas Health Readmission Indicator List (THRIL) scores daily, identify high-risk patients, promote discussion and assist in identifying a primary care physician (PCP), and complete Transition Evaluations within 24 hours of identification to begin discharge planning. The role also includes interviewing and assessing patients and caregivers, and identifying transition needs while 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
- 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
- Collaborates with physicians, staff, patients, and families to determine discharge needs.
- Ensure open communication with daily Interdepartmental rounds with charge RN, physicians and CTMs to ensure all agree of discharge plan.
Benefits
- 401k
- PTO
- medical
- dental
- Paid Parental Leave
- flex spending
- tuition reimbursement
- student Loan forgiveness
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What This Job Offers
Job Type
Part-time
Career Level
Mid Level
