Care Transition Social Worker
Bring your passion to Texas Health so we are Better + Together
Work location: Texas Health Flower Mound 4400 Long Prairie Rd TX 75028
Work hours: PRN, Days
Department highlights:
- 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.
Here’s What You Need
Master’s Degree in 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 in hospital/medical social work Preferred and
1 Year discharge planning/care management Preferred
LMSW – Licensed Master Social Worker Upon Hire Required Or
LCSW – Licensed Clinical Social Worker Upon Hire Required And
CPR – Cardiopulmonary Resuscitation Upon Hire Required And
ACM – Accredited Case Manager Upon Hire Preferred Or
CCM – Certified Case Manager Upon Hire Preferred Or
Other- ANCC Upon Hire preferred
3 Years in hospital/medical social work Preferred and
1 Year discharge planning/care management Preferred
LMSW – Licensed Master Social Worker Upon Hire Required Or
LCSW – Licensed Clinical Social Worker Upon Hire Required And
CPR – Cardiopulmonary Resuscitation Upon Hire Required And
ACM – Accredited Case Manager Upon Hire Preferred Or
CCM – Certified Case Manager Upon Hire Preferred Or
Other- ANCC Upon Hire preferred
What You Will Do
Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner:
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 patient 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, visiting physician or other transitional care visit prior to discharge.
Identifies transition needs and discusses funding of post-transition care with patients and caregivers.
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 patient 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, visiting physician or other transitional care visit prior to discharge.
Identifies transition needs and discusses funding of post-transition care with patients and caregivers.
Additional perks of being a Texas Health employee
· Benefits include 401k, PTO, medical, dental, Paid Parental Leave, flex spending, tuition reimbursement, Student Loan Repayment Program 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.
Entity Highlights
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. As a result, we’ve been recognized as the best provider of healthcare services by our patients, peers and the community numerous times.
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!
Learn more about our culture, benefits, and recent awards.
Do you still have questions or concerns? Feel free to email your questions to recruitment@texashealth.org
#LI-RT1
Location: Flower Mound, TX US
Job ID: 25000600
Area of Interest: Social Services
Job Type: PRN
Facility: Texas Health Flower Mound 4400 Long Prairie Rd TX 75028
