Care Transition Manager, Social Worker

Care Transition Manager Social Worker
Bring your passion to Texas Health so we are Better Together

Work location:1301 Pennsylvania Ave. Fort. Worth TX 76104

Work hours: 7:00 AM 4:30 PM. This position requires one week of oncall coverage per year.

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

Heres What You Need:

Masters Degree Social Work required

3 years in hospital/ medical social work preferred

1 year discharge planning/care management preferred

LMSW - Licensed Master Social Worker Upon Hire required

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

Other ANCC Upon Hire preferred

What You Will Do

Completes Transition Evaluations and collects Social Determinants of Health (SDOH) data on patients within 48 hours of identification and begins discharge planning. Assesses and interviews patients and caregivers as part of this evaluation and as needed.

Reviews the Risk of Unplanned Readmission (RUR) scores daily for all assigned patients.

Assists in the identification of a primary care physician (PCP) for patients without a PCP and attempts to schedule follow up appointments with either a PCP specialist clinic physician or other transitional care visit prior to discharge.

Identifies transition needs and discusses funding of post-transition care with patients and caregivers.

Participates in multidisciplinary rounds (MDRs) to help identify current length of stay (LOS) expected discharge date anticipated discharge disposition barriers to discharge avoidable days and potential denials.

Coordinates/facilitates patient care progression throughout the continuum with the objective of enhancing quality clinical outcomes and safe discharge planning to the appropriate levels of care for high-risk patient populations.

Coordinates with patients and families to manage chronic conditions and ensures appropriate post-discharge clinical follow up.

Additional perks of being a Texas Health RN Nurse:

Benefits include 401k PTO medical dental paid Parental Leave flex spending tuition reimbursement student Loan forgiveness as well as several other benefits

Delivery of high quality of 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

Texas Health Fort Worth is an 851-bed Magnet-designated full-service hospital that has served the Fort Worth community since 1930.

We offer advanced care in cardiovascular services high-risk obstetrics gynecology neurosciences sports medicine and emergency medicine. Our hospital also features certified programs in Advanced Hip and Knee Replacement Brain Tumor Treatment Advanced Spine Care and Advanced Palliative Care. We are also home to a kidney transplant program that underscores our high-acuity capabilities and we support Graduate Medical Education (GME) to help train the next generation of physicians.

Texas Health Fort Worth is Joint Commission-certified as a Comprehensive Cardiac Center a Comprehensive Stroke Center and a Level I Trauma Center. We are also a designated Magnet hospital and recognized as the Best Place to Have a Baby in Tarrant County. Texas Health Fort Worth continues to be a top choice in North Texas for emergency services womens health cardiac care and more.

If youre ready to join us in our mission to improve the health of our community then lets show the world how were even better together!

Learn more about our culture benefits and recent awards.

Do you still have questions or concerns
Feel free to email your questions to

#LI- LJ1

#justintower!