Care Transition Manager Social Worker PRN
Boost your chances before you apply.
Texas Health Resources
Cleburne, TX, US
Summary
The Care Transition Manager ensures patients are transitioned to the appropriate level of care in a timely and effective manner. This includes conducting transition evaluations, identifying community resources, and collaborating with interdisciplinary teams to manage high-risk patients.
Job Description
Care Transition Manager Social Worker LMSW/LCSW
Bring your passion to Texas Health so we are Better + Together
Work location: Texas Health Cleburne 201 Walls Dr. Cleburne, TX 76033
Work hours: PRN Days - Between 8:00 am - 5p to cover sick/pto time. Occasional weekends required(Saturday on site 8am-5p and Sunday can be remote or on site between 8am-5p)
Department highlights:
· Robust Unit Based Council (UBC) and engaged leadership team
· The Care Transition team ensures that patients are transitioned to appropriate level of care in a timely and effective manner. Provides education, care and resources to patients across various specialties to identify transition needs and discuss post- acute care options
· Manageable Case Load
· Team that works together to ensure work life balance for all
Here’s What You Need
· Master's Degree Social Work Required (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)
· 3 Years’ experience in hospital/medical social work Preferred
· 1 Year discharge planning/care management Preferred
· LMSW - Licensed Master Social Worker Upon Hire Required Or
LCSW - Licensed Clinical Social Worker Upon Hire Required
· CPR - Cardiopulmonary Resuscitation Upon Hire Required
· ACM - Accredited Case Manager Upon Hire Preferred
· CCM - Certified Case Manager Upon Hire Preferred Or
Other ANCC Upon Hire Preferred
What You Will Do
• 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 and discharge planning
• Strong oral and written communication skills
• Strong commitment to interdisciplinary collaboration
• Critical thinking, analysis and conflict resolution skills
• Psychosocial and crisis intervention skills
• Ability to prioritize and meet deadlines
• Identify community resources and service needs and facilitate appropriate referrals as needed.
• 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
Additional perks of being a Texas Health Social Worker
· Benefits include 401k, discounts in the cafeteria.
· A supportive, team environment with outstanding 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 [email protected]
At Texas Health Resources, our mission is to improve the health of the people in the communities we serve.
We are one of the largest faith-based, nonprofit health systems in the United States with a team of more than 28,000 employees of wholly owned/operated facilities and consolidated joint ventures in the greater Dallas Fort Worth area. Our career growth and professional development opportunities are top-notch and our benefits are equally outstanding.
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.
Let us brag for a minute on just a few of our recent accomplishments.
• Fortune’s 100 Best Companies to Work For® 2026
• Business Group on Health Best Employers: Excellence in Health & Well-being 2026 and Excellence in Mental Health
• 20 Best Workplaces in Health Care by Great Place to Work® and Fortune 2025
• Companies That Care® by PEOPLE magazine and Great Place to Work® 2025
• America’s Best Large Employers by Forbes for 2025
• Fortune’s Best Workplaces for Women™ 2025
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.
Founded
1997
Company size
10,001+ employees
Industry
Hospitals and Health Care
Org type
Nonprofit
Headquarters
Arlington, Texas
At Texas Health Resources, our mission is to improve the health of the people in the communities we serve.
We are one of the largest faith-based, nonprofit health systems in the United States with a team of more than 28,000 employees of wholly owned/operated facilities and consolidated joint ventures in the greater Dallas Fort Worth area. Our career growth and professional development opportunities are top-notch and our benefits are equally outstanding.
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.
Let us brag for a minute on just a few of our recent accomplishments.
• Fortune’s 100 Best Companies to Work For® 2026
• Business Group on Health Best Employers: Excellence in Health & Well-being 2026 and Excellence in Mental Health
• 20 Best Workplaces in Health Care by Great Place to Work® and Fortune 2025
• Companies That Care® by PEOPLE magazine and Great Place to Work® 2025
• America’s Best Large Employers by Forbes for 2025
• Fortune’s Best Workplaces for Women™ 2025
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.
Founded
1997
Company size
10,001+ employees
Industry
Hospitals and Health Care
Org type
Nonprofit
Headquarters
Arlington, Texas