Care Transition Manager Social Worker LMSW PRN

Care Transition Manager Social Worker - PRN LMSW or LCSW _Bring your passion to Texas Health so we are Better + Together_ Work location: Texas Health Southwest Ft. Worth, 6100 Harris Parkway, Fort Worth, TX 76132, will also assist at Texas Health Clearfork 5400 Clearfork Main Street, Ft. Worth 76109 Work hours: PRN, on an as needed basis, some weekends: (2) 8-hour Weekend shifts per month; between 8:00AM-5:00PM mainly Monday-Friday, cover for leaves of absence, vacation, illnesses. Care Transition Department highlights: + Care Transition management - will float to various specialty areas as needed Magnet status, Level II Trauma facility, Stroke & Chest pain certified, Hip & Knee Orthopedics certified. 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 Or CCM - Certified Case Manager Upon Hire Preferred Or Other ANCC Upon Hire Preferred Working knowledge of medical necessity criteria preferred + Knowledge of Microsoft Outlook and Office (Word, Excel) + Customer service skills, Psychosocial and crisis intervention skills + Ability to engage in complex clinical decision-making, Critical thinking, analysis and conflict resolution skills + Strong oral and written communication skills + Strong commitment to interdisciplinary collaboration + Flexible scheduling as necessary + Ability to prioritize and meet deadlines What You Will Do 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. Interviews and assesses patients and caregivers as part of the transition evaluation and as needed. Identifies transition needs and discusses funding of post-transition care with patients and caregivers. Identifies Geometric Mean Length of Stay (GMLOS) and updates the Anticipated Date of Discharge (ADOD) as necessary while considering excess days risk. Identifies community resources and service needs and facilitates appropriate referrals as needed. Communicates with the multidisciplinary team (physicians, nursing, therapy), patient, family and post-acute care stakeholders in order to coordinate care. Educates, patients, caregivers, and the multidisciplinary team regarding available post-acute care services and needs. Facilitates care conferences for complex transitions, placement and palliative care needs. Proactively identifies patients who no longer meet continued stay criteria and communicates with the physician team. Attempts to schedule PCP, specialist or clinic follow up appointments for patients. Responsible for compliance with documentation guidelines and regulatory agency requirements: Complies with all documentation requirements and documents all activities in the electronic health record. Adheres to compliance requirements for delivery of various documents (e.g. HINN, IMM, MOON letters). Has a working knowledge of the following documents: Advanced Directives, Medical Power of Attorney, Application for Temporary Mental Health Treatment, and out-of-hospital Do Not Resuscitate. Participates in Joint Commission and other survey readiness activities Additional perks of being a Texas Health Care Transition Manager Social Worker Benefits include 401k, discounts in the cafeteria and free parking. 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: 2026-02-09