Care Transition Social Worker - Full Time Days

#REF!•Cleburne, TX

3d•Onsite

About The Position

The Care Transition Social Worker is responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner. This role involves reviewing patient scores, collaborating with the interdisciplinary team, identifying high-risk patients, promoting primary care physician discussions, and completing transition evaluations within 24 hours of identification to begin discharge planning. The team works together to ensure work-life balance for all.

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
Working knowledge of medical necessity criteria preferred
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

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.