Job Information

Texas Health Resources Care Transition Manager Social Worker in Azle, Texas

Are you looking for a rewarding career with family-friendly hours and top-notch benefits? We are looking for a qualified Care Transition Manager Social Worker like you to join our Texas Health family.

Position Highlights:

  • Work location: Texas Health Azle; 108 Denver Trail Azle TX 76020.

  • Department: Care Management Department

  • Work hours: PRN – As Needed; Day Shift; Variable hours as needed.

  • Salary range: $30.25 – $49.50per hour (based on relevant experience)

Texas Health Azle is 36 bed small community hospital that provides exceptional care to Suburban areas of Azle, Lake Worth, Springtown and surrounding areas. Texas Health Azle is a Joint Commission – Certified Level III Stroke Center a Level IV Trauma Center and accredited Chest Pain Management facility. Join our award-winning Texas Health family and become a part of a team that is improving the health of our communities daily. You belong here!


  • Master’s Degree in Social work required.


  • 3 years of experience in hospital/medical social work preferred and

  • 1 year of experience of discharge planning/care management

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 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.

  • Critical thinking, analysis, and conflict resolution skills.

  • Flexible scheduling, as necessary.

  • Psychosocial and crisis intervention skills.

  • Ability to prioritize and meet deadlines.

Position Responsibilities:

Essential Functions:

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.

Why Texas Health? As a Care Transition Manager Social Worker, you’ll enjoy top-notch benefits including 401(k) with match, paid time off, competitive health insurance choices, healthcare and dependent care spending account options, wellness programs to keep you and your family healthy, tuition reimbursement, a student loan repayment program and more.

At Texas Health Plano, our people make this a great place to work every day. Our inclusive, supportive, people-first, excellence-driven culture make Texas Health Resources a great place to work.

Here are a few of our recent awards:

  • 2021 FORTUNE Magazine’s “100 Best Companies to Work For®” (7 th year in a row)

  • Becker's Healthcare "150 Great Places to Work in Healthcare" (4 years running)

  • “America’s Best Employers for Diversity” list by Forbes

  • A “100 Best Workplaces for Millennials" by Fortune and Great Place to Work®

Additional perks of being Care Transition Manager Social Worker:

  • Gain a sense of accomplishment by contributing to a teamwork environment.

  • Receive excellent mentorship, comprehensive training, and dedicated leadership resources.

  • Enjoy opportunities for growth.

Explore our Texas Health careers site for info like Benefits , Job Listings by Category , recent Awards we’ve won and more.

Do you still have questions or concerns? Feel free to email your questions to .

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.