Care Transition Social Worker - Full Time Days

Texas Health Resources•Cleburne, TX

4d•Onsite

About The Position

The Care Transition team ensures that patients are transitioned to appropriate level of care in a timely and effective manner. Provides education, care and resources to patients across various specialties to identify transition needs and discuss post-acute care options. This role involves working with patients to identify community resources and service needs, facilitating appropriate referrals, and ensuring patients are transitioned to appropriate levels of care. The social worker will review the Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients and collaborate with the interdisciplinary team to identify high-risk patients. They will also promote discussion and assist in the identification of a primary care physician (PCP) for patients without one, and complete Transition Evaluations within 24 hours of identification to begin discharge planning.

Requirements

Master's Degree 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
Knowledge of Microsoft Outlook and Office (Word, Excel)
Customer service skills
Ability to engage in complex clinical decision-making and discharge planning
Strong oral and written communication skills
Strong commitment to interdisciplinary collaboration
Critical thinking, analysis and conflict resolution skills
Psychosocial and crisis intervention skills
Ability to prioritize and meet deadlines

Nice To Haves

3 Years’ experience in hospital/medical social work Preferred
1 Year discharge planning/care management Preferred
ACM - Accredited Case Manager Upon Hire Preferred
CCM - Certified Case Manager Upon Hire Preferred Or Other ANCC Upon Hire Preferred
Working knowledge of medical necessity criteria preferred

Responsibilities

Identify community resources and service needs and facilitate appropriate referrals as needed.
Responsible for ensuring 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 and collaborates with the interdisciplinary team to identify high risk patients whose THRIL score may not have indicated appropriately.
Promotes discussion and assists in the identification of a primary care physician (PCP) for patients without a PCP.
Completes Transition Evaluations on patients within 24 hours of identification and begins discharge planning.