Job Information

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

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

Position Highlights

  • Work location: 201 Walls Drive, Cleburne TX 76033

  • Work environment: Direct Patient Care -Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner across all specialties within the hospital.

  • Work hours: PRN Days, As needed on Monday- Friday 8:00am-4:30pm or Saturday and Sunday 7:00am-7:00pm

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

Texas Health Cleburne Hospital is a 137 bed Pathway to Excellence Hospital and is recognized for using evidence-based clinical processes for heart failure, pneumonia and surgical care. Located about 35 miles south of Fort Worth, hospital services include surgery, women’s care, gastroenterology, orthopedics and ear, nose and throat care. The center has over 80 physicians on its medical staff and has been recognized as a Top Performer for Quality Care in a nationwide performance improvement project, an accredited Chest Pain Center by the Society of Chest Pain Centers, and designated a Pathway to Excellence® hospital by the American Nurses Credentialing Center. Recognitions like these make our facility intensely qualified to serve our community and your professional aspirations. We are one of the largest faith-based, nonprofit health care delivery systems in the US that has the resources to offer a variety of career growth and professional development opportunities with equally remarkable benefits. Join our award-winning Texas Health family and contribute to our mission “to improve the health of the people in the communities we serve”.

  • 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. Req

  • LMSW - Licensed Master Social Worker Upon Hire required Or LCSW - Licensed Clinical Social Worker Upon Hire required

  • CPR - Cardiopulmonary Resuscitation Upon Hire

  • ACM - Accredited Case Manager Upon Hire preferred OrCCM - Certified Case Manager Upon Hire preferred OROther ANCC Upon Hire preferred

  • 3 Years in hospital/medical social work preferred

  • 1 Year discharge planning/care management preferred

Position Responsibilities Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner. In addition to the required qualifications, a successful RN will:

  • 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.

  • Obtains social, physical, psychological and financial histories from available resources. Assesses patient information utilizing medical knowledge. Identifies reasons contributing to patient readmissions.

  • Ensures patients are provided post-acute options based on clinical necessity and patient choice while also considering the payor source

  • Responsible for compliance with documentation guidelines and regulatory agency requirements

  • Compliance requirements for delivery of HINN, second IMM and MOON letters

  • Potential denials, avoidable days, and alternate level of care days

  • Clinical review staff requirements and communications

  • 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

  • Performs other duties as assigned.

Why Texas Health As a Texas Health RN 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, our people make this a great place to work every day. Our inclusive, supportive, people-first, excellence-driven culture make THPG a great place to work.

Here are a few of our recent awards:

  • 2021 FORTUNE Magazine’s “100 Best Companies to Work For®” (7th 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®

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

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.