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Texas Health Resources Care Transition Manager Social Worker - Full Time Days - Plano in Plano, Texas

Texas Health Plano seeks to hire a Care Transition Manager – Social Worker to Full Time Days, 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.

Work Schedule:

  • Full Time; 40 Hours

  • Monday – Friday; 1 st Shift

Job Description:

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.

Qualifications

The ideal candidate will possess the following qualifications:

  • Master’s Degree in Social Work required

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

  • 1-year discharge planning/care management preferred

  • Must have 2 years recent hospital case management experience

  • Experience with high risk populations 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 and

  • ACM - Accredited Case Manager upon hire preferred or

  • CCM - Certified Case Manager upon hire preferred or

  • Other – ANCC upon hire preferred

Skills:

  • 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 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:

  • 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.

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