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Texas Health Resources Care Transition Manager Social Worker - As Needed - Allen in Allen, Texas

Texas Health Allen seeks to hire a Care Transition Manager – Social Worker to PRN As Needed Days, for the Care Management Department.

The address is 1105 Central Expressway North, Allen, TX 75013.

Salary range is Minimum $27.00/hr. to Maximum $46.28/hr. – based on relevant experience

Work Schedule:

  • PRN – “As Needed”

  • 8:00 am – 4:30 pm

  • One weekend per month; weekday coverage as needed

Job Description:

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.

  • Assigns patients to and supports appropriate transition programs (e.g. ACO members) when applicable.

  • 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.

  • Executes and updates the discharge plan as needed.

  • Communicates final transition plan 24-48 hours prior to transition.

  • Facilitates care conferences for complex transitions, placement and palliative care needs.

  • Serves as a point of contact for all identified stakeholders.

Ensures patients are provided post-acute options based on clinical necessity and patient choice while also considering the payor source:

  • Serves as a content expert regarding payor information. Educates the multidisciplinary team, patients and caregivers regarding payor requirements and barriers.

  • Communicates with payors as needed.

  • 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

Serves as a content expert on the following:

  • Compliance requirements for delivery of HINN, second IMM and MOON letters

  • Potential denials, avoidable days, and alternate level of care days

  • Medical necessity, patient status and discharge criteria

  • Clinical review staff requirements and communications


The ideal candidate will possess the following qualifications:

  • Master’s Degree in Social Work required

  • 3 years’ experience in Social Work preferred

  • 1 year discharge planning/care management preferred

  • 2 years recent acute hospital experience highly preferred

License and Certification:

  • 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

  • Other ANCC upon hire preferred


  • 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

  • Strong oral and written communication skills

  • Strong commitment to interdisciplinary collaboration

  • Critical thinking and analysis and conflict resolution skills

  • Flexible scheduling as necessary

  • Psychosocial and crisis intervention skills

  • Ability to prioritize and meet deadlines.

Why Texas Health Resources?

Texas Health Presbyterian Hospital Allen is a 73-bed, acute-care hospital serving the northern Collin County area since 2000. Hospital services include women’s care, a Level II neonatal intensive care unit, orthopedics, pediatrics, wound care and sleep medicine. Texas Health Allen, a Pathway to Excellence® designated hospital by the American Nurses Credentialing Center, has more than 500 physicians on its medical staff practicing in more than 25 specialties. Texas Health Allen is a World Health Organization-designated "Baby-Friendly Hospital" and was the first hospital in Texas to receive the distinction. The hospital is a Level IV trauma center and an Accredited Chest Pain Center by the Society of Chest Pain Centers, which makes our facility intensely qualified to serve our community and your professional aspirations.

Texas Health Highlights:

  • 2020 FORTUNE Magazine’s “100 Best Companies to Work For®” (6th year in a row)

  • 2018 Becker's Healthcare "150 Great Places to Work in Healthcare" (4th year in a row)

  • Employees’ Choice “Best Places to Work” by Glassdoor (2018 and 2019)

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.