Texas Health Resources Social Worker Care Transition Full-time Days Dallas in Dallas, Texas

Job Description

Responsible for ensuring patients are timely and effectively transitioned to appropriate levels of care

Actively participates in Daily Patient Care Briefings and identifies patients appropriate for transition needs intervention.

Reviews Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients.

Collaborates with interdisciplinary team to identify high risk patients whose THRIL score may not have indicated appropriately.

Ensures all assigned patients have an identified Primary Care Physician (PCP). If PCP not identified, exhaust all efforts in an attempt to assign.

Completes Transition Evaluation on all identified patients within 24 hours of referral documents appropriately.

Interviews/Assesses patients / caregivers as part of transition evaluation and as needed.

Identifies transition needs (including medications), develops transition plan within 24 hours of referral, and discusses funding of post transition care with patients / caregivers documents appropriately.

Validates transition plan with Interdisciplinary Team (Physician, Clinical Nurse Leader, Nursing, etc.).

Updates Estimated Transition Date (ETD) as needed.

Educates interdisciplinary team and patients / caregivers regarding available post acute care services and needs.

Communicates transition plan and post acute management plan with patients / caregivers and post acute care stakeholders.

Executes and updates transition plan and post acute management plan as needed.

Facilitates care conferences for complex transitions and/or placement.

Identifies community resources / service needs Facilitates appropriate referrals as needed (acute and non-acute).

Actively communicates with all appropriate post acute care providers throughout patient stay. Communicates final transition plan 24 - 48 hours prior to transition.

Serves as a point of contact for all identified stakeholders.

Assigns patients to appropriate transition program(s) (i.e. NTSP, THPG or based on payor preferences) and provides support as needed 60%

Ensures patients are placed appropriately following discharge and that necessary follow up takes place with patients as well as payors.


Social Worker Care Transition


8200 Walnut Hill Lane Dallas, TX 75231

Salary Range:

Min: $20.34 per hour – Max: $39.50 per hour


Master's Degree Social Work 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. Required


3 Years Social work Required

Recent experience in acute care hospital Preferred

Licenses and Certifications

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


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

Psychosocial and crisis intervention skills

Position requires flexible scheduling, including weekend and evening shift work as necessary

Ability to prioritize and meet deadlines.

Preferred experience with electronic health record and automated case management systems.

Individual must be self-directed and goal/outcomes/measurement driven

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.