Texas Health Resources
Social Worker (SW) Care Transition Manager - PRN
Texas Health Resources, Arlington, Texas, United States, 76000
Social Worker (SW) Care Transition Manager – PRN
Location:
Texas Health Arlington, 800 W. Randol Mill Road, TX 76012
Work hours:
PRN
Department Highlights
Team based environment.
Workplace culture 2nd to none.
We operate on lean principles and rely on team atmosphere and individual performance.
Highly engaged management.
What You Will Do
Ensure patients are transitioned to appropriate levels of care in a timely and effective manner.
Complete transition evaluations and collect socioeconomic data within 48 hours of identification, beginning discharge planning.
Assess and interview patient and caregivers during evaluation.
Review the Risk of Unplanned Readmission (RUR) scores daily for assigned patients.
Assist in identifying a primary care physician for patients without a PCP, and schedule follow‑up appointments.
Identify transition needs and discuss funding of post‑transition care with patients and caregivers.
Participate in multidisciplinary rounds to determine LOS, discharge date, disposition, barriers, avoidable days, and potential denials.
Coordinate patient care progression throughout the continuum, enhancing outcomes and safe discharge planning for high‑risk populations.
Coordinate with patients and families to manage chronic conditions and ensure appropriate post‑discharge follow‑up.
Proactively identify patients who no longer meet continued stay criteria and communicate with the physician team.
Assign patients to and support appropriate transition programs (e.g., ACO members) when applicable.
Update and execute the discharge plan as needed.
Communicate final transition plan 24–48 hours prior to transition.
Facilitate care conferences for complex transitions, placement, and palliative care needs.
Serve as point of contact for all identified stakeholders.
Identify and document barriers to discharge, working to resolve obstacles that impede diagnostics or treatment.
Assist patients with complex psychosocial needs; offer solution‑focused interventions when needed.
Assist with eligibility determination for funding sources and community resources (housing, food, mental health services).
Collaborate with Palliative and Pastoral Care to provide end‑of‑life support; facilitate referrals to appropriate agencies.
Provide intervention in cases involving child or elder abuse/neglect.
50% of time: Ensure post‑acute options based on clinical necessity; review care options and utilize existing protocols to facilitate continuity within the Texas Health network.
30% of time: Schedule/coordinate patient clinical needs to appropriate post‑acute care facility; identify community resources and facilitate referrals; educate team on payor information.
20% of time: Maintain compliance with documentation guidelines and regulatory agency requirements; document all activities in the electronic health record; participate in survey readiness activities.
What You Need Education
Master’s Degree in Social Work.
Individuals hired as a CTSW prior to May 11, 2017 will be grandfathered to the CTSW position with BSW at the entity they were employed at on that date.
Experience
3 years in hospital/medical social work (preferred).
1 year in discharge planning/care management (preferred).
Licenses and Certifications
LMSW – Licensed Master Social Worker (required upon hire).
LCSW – Licensed Clinical Social Worker (required upon hire).
CPR – Cardiopulmonary Resuscitation (required upon hire).
ACM – Accredited Case Manager (preferred).
CCM – Certified Case Manager (preferred).
Other ANCC certifications (preferred).
Skills
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.
Strong oral and written communication skills.
Strong commitment to interdisciplinary collaboration.
Critical thinking, analysis, and conflict resolution skills.
Flexible scheduling.
Psychosocial and crisis intervention skills.
Ability to prioritize and meet deadlines.
ADA Requirements
Extreme heat: 1–33%.
Extreme cold: 1–33%.
Extreme temperature swings: 1–33%.
Extreme noise: 1–33%.
Working outdoors: 1–33%.
Working indoors: 67% or more.
Mechanical hazards: 1–33%.
Electrical hazards: 1–33%.
Explosive hazards: 1–33%.
Fume/odor hazards: 1–33%.
Dust/mite hazards: 1–33%.
Chemical hazards: 1–33%.
Toxic waste hazards: 1–33%.
Radiation hazards: 1–33%.
Wet hazards: 1–33%.
Heights: 1–33%.
Other conditions: 1–33%.
Physical Demands Light work.
Employment information
Seniority level: Not Applicable.
Employment type: Full‑time (PRN availability).
Job function: Other.
Industries: Hospitals and Health Care.
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Texas Health Arlington, 800 W. Randol Mill Road, TX 76012
Work hours:
PRN
Department Highlights
Team based environment.
Workplace culture 2nd to none.
We operate on lean principles and rely on team atmosphere and individual performance.
Highly engaged management.
What You Will Do
Ensure patients are transitioned to appropriate levels of care in a timely and effective manner.
Complete transition evaluations and collect socioeconomic data within 48 hours of identification, beginning discharge planning.
Assess and interview patient and caregivers during evaluation.
Review the Risk of Unplanned Readmission (RUR) scores daily for assigned patients.
Assist in identifying a primary care physician for patients without a PCP, and schedule follow‑up appointments.
Identify transition needs and discuss funding of post‑transition care with patients and caregivers.
Participate in multidisciplinary rounds to determine LOS, discharge date, disposition, barriers, avoidable days, and potential denials.
Coordinate patient care progression throughout the continuum, enhancing outcomes and safe discharge planning for high‑risk populations.
Coordinate with patients and families to manage chronic conditions and ensure appropriate post‑discharge follow‑up.
Proactively identify patients who no longer meet continued stay criteria and communicate with the physician team.
Assign patients to and support appropriate transition programs (e.g., ACO members) when applicable.
Update and execute the discharge plan as needed.
Communicate final transition plan 24–48 hours prior to transition.
Facilitate care conferences for complex transitions, placement, and palliative care needs.
Serve as point of contact for all identified stakeholders.
Identify and document barriers to discharge, working to resolve obstacles that impede diagnostics or treatment.
Assist patients with complex psychosocial needs; offer solution‑focused interventions when needed.
Assist with eligibility determination for funding sources and community resources (housing, food, mental health services).
Collaborate with Palliative and Pastoral Care to provide end‑of‑life support; facilitate referrals to appropriate agencies.
Provide intervention in cases involving child or elder abuse/neglect.
50% of time: Ensure post‑acute options based on clinical necessity; review care options and utilize existing protocols to facilitate continuity within the Texas Health network.
30% of time: Schedule/coordinate patient clinical needs to appropriate post‑acute care facility; identify community resources and facilitate referrals; educate team on payor information.
20% of time: Maintain compliance with documentation guidelines and regulatory agency requirements; document all activities in the electronic health record; participate in survey readiness activities.
What You Need Education
Master’s Degree in Social Work.
Individuals hired as a CTSW prior to May 11, 2017 will be grandfathered to the CTSW position with BSW at the entity they were employed at on that date.
Experience
3 years in hospital/medical social work (preferred).
1 year in discharge planning/care management (preferred).
Licenses and Certifications
LMSW – Licensed Master Social Worker (required upon hire).
LCSW – Licensed Clinical Social Worker (required upon hire).
CPR – Cardiopulmonary Resuscitation (required upon hire).
ACM – Accredited Case Manager (preferred).
CCM – Certified Case Manager (preferred).
Other ANCC certifications (preferred).
Skills
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.
Strong oral and written communication skills.
Strong commitment to interdisciplinary collaboration.
Critical thinking, analysis, and conflict resolution skills.
Flexible scheduling.
Psychosocial and crisis intervention skills.
Ability to prioritize and meet deadlines.
ADA Requirements
Extreme heat: 1–33%.
Extreme cold: 1–33%.
Extreme temperature swings: 1–33%.
Extreme noise: 1–33%.
Working outdoors: 1–33%.
Working indoors: 67% or more.
Mechanical hazards: 1–33%.
Electrical hazards: 1–33%.
Explosive hazards: 1–33%.
Fume/odor hazards: 1–33%.
Dust/mite hazards: 1–33%.
Chemical hazards: 1–33%.
Toxic waste hazards: 1–33%.
Radiation hazards: 1–33%.
Wet hazards: 1–33%.
Heights: 1–33%.
Other conditions: 1–33%.
Physical Demands Light work.
Employment information
Seniority level: Not Applicable.
Employment type: Full‑time (PRN availability).
Job function: Other.
Industries: Hospitals and Health Care.
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