Social Worker, Care Transition Manager, PRN

Social Worker, Care Transition Manager, PRN, Days

Posted 1 day ago. Be among the first 25 applicants.

Bring your passion to Texas Health so we are Better + Together.

Texas Health Flower Mound, 4400 Long Prairie Rd, TX 75028.

PRN, Days.

• Modern facility and high‑tech equipment.
• Great team dynamics that provide a great support.
• The department prides itself in high‑performing staff with excellent critical thinking skills.

• Master's Degree in Social Work required.
• 1 year in hospital/medical social work highly preferred; 2 or more years preferred.
• 1 year discharge planning/care management preferred.
• Licensed Master Social Worker (LMSW) required upon hire.
• Licensed Clinical Social Worker (LCSW) required upon hire.
• CPR certification required upon hire.
• Accredited Case Manager (ACM) preferred upon hire.
• Certified Case Manager (CCM) preferred upon hire.
• Other: ANCC preferred.

Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner:

• Complete Transition Evaluations and collect Social Determinants of Health (SDOH) data on patients within 48 hours of identification and begin discharge planning. Assess and interview patient and caregivers as part of this evaluation and as needed.
• Review the Risk of Unplanned Readmission (RUR) scores daily for all assigned patients.
• Assist in the identification of a primary care physician (PCP) for patients without a PCP and attempt to schedule follow‑up appointments with either a PCP, specialist, clinic, visiting physician or other transitional care visit prior to discharge.
• Identify transition needs and discuss funding of post‑transition care with patients and caregivers.

• Benefits include 401(k), PTO, medical, dental, paid parental leave, flex spending, tuition reimbursement, student loan repayment program, and several other benefits.
• Delivery of high quality patient care through nursing education, nursing research and innovations in nursing practice.
• Strong Unit Based Council (UBC).
• A supportive, team environment with outstanding opportunities for growth.

99‑bed facility with more than 500 physicians on our medical staff who practice a full range of specialties. In addition to our modern facility and high‑tech equipment, we have a dedicated team of physicians and staff who go above and beyond to provide the highest quality medical care to every patient who comes through our door. Recognized as the best provider of healthcare services by our patients, peers and the community numerous times.

• Seniority level:
  Not applicable.
• Employment type:
  
  Full‑time.
• Job function:
  Other.
• Industries:
  Hospitals and Health Care.

If you’re ready to join us in our mission to improve the health of our community, then let’s show the world how we’re even better together! Feel free to email your questions to recruitment.