Texas Health Resources Care Transition Manager Social Worker - As Needed Days - HEB in Bedford, Texas
Texas Health Hurst-Euless-Bedford seeks to hire a Care Transition Manager – Social Worker to work PRN – As Needed Days the Care Management Department.
The address is 1600 Hospital Parkway, Bedford, TX 76022.
Salary range is Minimum $27.00/hr. to Maximum $46.28/hr. – based on relevant experience
PRN – As Needed
Monday – Friday; 8:00am – 4:30 pm
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 in hospital/medical in Social Work experience preferred
1 year discharge planning/care management preferred
Experience in Hospital Case Management 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, 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 Harris Methodist Hospital Hurst-Euless-Bedford is a 296-bed, acute-care facility serving Northeast Tarrant County since 1973. With more than 550 physicians on its medical staff, hospital services include outpatient surgery, women’s services, a Level III neonatal intensive care unit, a dedicated oncology unit and cardiac rehabilitation. Texas Health HEB recently received a dual accreditation as a Cycle IV Chest Pain Center and Heart Failure Center by the Society of Chest Pain Centers, is certified as a Primary Stroke Center and a designated "Baby Friendly" facility by WHO and UNICEF. Our location brings the best of suburban living, offering you the benefits of convenience and solid career opportunities.
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.