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

Texas Health Arlington seeks to hire a Care Transition Manager – Social Worker to work As Needed in the Care Management Department.

The address is 800 W. Randol Mill Road, TX 76012

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

Work Schedule:

  • PRN – As Needed

  • Hours and shift will vary throughout the week

Job Description:

Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner:

  • Reviews Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients and collaborates with the interdisciplinary team identify high risk patients whose THRIL score may not have indicated appropriately.

  • Promotes discussion and assists in the identification of primary care physician (PCP) for patients without a PCP.

  • Completes Transition Evaluation on all identified patients within 24 hours of identification and begins discharge planning.

  • Interviews and assesses patients and caregivers as part of transition evaluation as needed.

  • 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.

  • Updates Estimated transition Date (ETD as needed.

  • Educates interdisciplinary team and patients/caregivers 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 context expert regarding payor information.

  • Educates the multidisciplinary team, patients and caregivers regarding payor requirements and barriers.

  • Communicates with payors as appropriate.

  • Proactively identifies patients who no longer meet continued stay criteria and communicates with the physician team.

  • Attempts to schedule PCP, specialist or clinical follow up appointments for patients.

Responsible for compliance with documentation guidelines and regulatory agency requirements:

  • Compiles 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 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 upon hire required or

  • 3 years’ experience in Social Work preferred and

  • 1 year hospital discharge planning/care management preferred

  • 3-5 years of recent experience in acute care hospital 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 or

  • 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 and communication

  • Strong skills in the preparation of clinically pertinent medical record documentation

  • Critical thinking and analysis skills 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 Arlington Memorial Hospital, a 369-bed acute-care, full-service medical center has been serving Arlington and the surrounding communities since 1958. Hospital services include comprehensive cardiac care, women’s services, neurosciences, cancer services, orthopedics, emergency services and an advanced imaging center. Texas Health Arlington Memorial has over 1,600 employees, 250 volunteers and 630 physicians on its medical staff. We invite you to join us in furthering your career and our accomplishments and philosophy of excellence. For more information, visit TexasHealth.org/Arlington.

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.