Care Transition Manager Social Worker LMSW PRN

Care Transition Manager Social Worker LMSW/LCSW PRN _Bring your passion to Texas Health so we are Better + Together_ Work location: Texas Health Ft. Worth, 1301 Pennsylvania Avenue, Ft. Worth, TX 76104 Care Transition Management department + Work hours: PRN, mainly weekdays between 7:30AM-5:00PM, on an as needed basis, Weekends are optional; During training, hours will vary between 7:30AM-5:30PM + (Does Require 5-weeks of training Monday to Friday) Care Transition Management department highlights: Supporting the 815-bed, Magnet-designated, full-service hospital that has served the Ft. Worth and surrounding community since 1930 Care Transition is a rewarding career with family-friendly hours Here's What You Need Master's Degree Social Work Required (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 May 11, 2017) 3 Years' experience in hospital/medical social work Preferred 1 Year discharge planning/care management Preferred LMSW - Licensed Master Social Worker Upon Hire Required Or LCSW - Licensed Clinical Social Worker Upon Hire Required CPR - Cardiopulmonary Resuscitation Upon Hire Required ACM - Accredited Case Manager Upon Hire Preferred CCM - Certified Case Manager Upon Hire Preferred Or Other ANCC Upon Hire Preferred What You Will Do 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 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 Additional perks of being a Texas Health Social Worker Benefits include 401k, discounts in the cafeteria. A supportive, team environment with outstanding opportunities for growth. Explore our Texas Health careers site ( for info like Benefits (, Job Listings by Category (, recent Awards ( we've won and more. _Do you still have questions or concerns?_ Feel free to email your questions to . #LI-JH1Texas Health requires a resume when an application is submitted.Employment opportunities are only reflective of wholly owned Texas Health Resources entities. We are an Equal Opportunity Employer and do not discriminate against any employees or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

Created: 2026-01-22