Texas Health Resources Care Transition Manager - Social Worker - As Needed in Plano, Texas
Texas Health Plano seeks to hire a Care Transition Manager – Social Worker to PRN “As Needed,” in the Care Management Department.
The address is 6200 West Parker Road, Plano, TX 75093.
Salary range is Minimum $27.00/hr. to Maximum $46.28/hr. – based on relevant experience
• PRN – “As Needed”; 8 hour shifts
• 8:00 am – 4:30 pm; 2 days per 4 week schedule
• May include weekend/holiday
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 poste 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 providers throughout patent stay. Communicates final transition plan 24-48 hours prior to transition.
• Serves as 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.
• Ensures patients are placed appropriately following discharge and that necessary follow up takes place with patients as well as payors.
• Serves as context expert regarding payor information. Educates interdisciplinary team and patients/caregivers regarding payor requirements and/or barriers.
• Facilitates care conferences for complex transition and/or placement.
• Identifies community resource/service needs; facilitates appropriate referrals as needed (acute and non-acute).
• Communicates with payors as appropriate.
• Monitors follow-up activities for all appropriate patients post hospitalization and supports patient transition plan adherence.
• Escalates issues to appropriate level of CTM leadership and coordinates mitigation activates as needed.
• Actively communicates with all appropriate post-acute care providers throughout patient stay.
• Communicates final transition plan 24-48 hours prior to transition. Serves as point of contact for all identified stakeholders.
• Ensures scheduling of follow-up PCP appointment (for patients not served by CNL/PCF).
• Schedules clinical follow up appointments in cases which PCP is unable to be identified/assigned (for patients not served by CNL/PCF).
• Responsible for compliance with documentation guidelines as well as regulatory agencies.
• Ensures transition plan and post-acute management plan consistency across settings.
• Compiles with all documentation requirements. Documents all activities in electronic health record.
• Adheres to compliance requirements; Code 44 intervention, HINN letters, Second IMM, Observation letter, etc.
• Has working knowledge of Advance Directives, Living Will, Medical Power of Attorney, Out of Hospital Do Not Resuscitate Order and Advanced Illness.
• Participates in Joint Commission readiness activities.
Serves as a content expert on the following:
• Psychosocial issues related to hospitalization and transition planning
• Child and Adult Protective Care Services cases (neglect, abuse, etc.); as appropriate.
• Complex psychiatric referrals
• Applications for community resource needs.
• Guardianship processes
• Mental Health Treatment Declaration – Order of Protective Custody
• Mental health court filings
• Indigent programs as appropriate
The ideal candidate will possess the following qualifications:
• Master’s Degree in Social Work required
• 3 years’ experience in Social Work required
• Recent experience in acute care hospital
License and Certification:
• LMSW - Licensed Master Social Worker upon hire or
• LCSW - Licensed Clinical Social Worker upon hire and
• CPR - Cardiopulmonary Resuscitation upon hire 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
Why Texas Health Resources?
Texas Health Presbyterian Hospital Plano is a 366-bed, Magnet-designated hospital and recognized clinical leader, providing technologically advanced care to Plano, Frisco and surrounding communities since 1991. This full-service facility features a full range of specialties including emergency medicine, cardiology, adult and adolescent behavioral health, pediatrics, an adult intensive care unit, state of the art and technologically advanced surgical services and a Level III NICU. Texas Health Plano has more than 1,600 employees and over 1,360 physicians on its medical staff in more than 65 specialties. The hospital is an Advanced Level III Trauma Facility, accredited Chest Pain Center by The Joint Commission, named “Best Place to Have a Baby” in Collin County and a Gold-Level Mother Friendly business. Texas Health Plano is the recipient of the Disease Specific Care Certifications from the Joint Commission in Chest Pain, Joint Replacement – Hip and Joint Replacement – Knee and an Advanced Certification as a Primary Stroke Center. We invite you to join us in furthering your career and our accomplishments and philosophy of excellence.
Texas Health Highlights:
• 2019 FORTUNE Magazine’s “100 Best Companies to Work For®” (5th 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.