Care Transition Manager, Social Worker - PRN, Days

Care Transition Manager Registered Nurse (RN) – Care Management Bring your passion to Texas Health. We Are Better + Together Location: Texas Health Allen, 1105 Central Expwy North, Allen, TX 75013 Work hours: PRN – 8:30–16:30, 2–4 weekend shifts plus additional weekday shifts to cover full‑time PTO. Care Transition Department Highlights Collaborates with physicians, staff, patients, and families to determine discharge needs. Ensures open communication with daily interdepartmental rounds with charge RN, physicians, and CTMs to agree on discharge plan. Supportive experienced coworkers. Here’s What You Need Master’s degree in social work required. Three years of experience in hospital/medical social work preferred. One year of experience in discharge planning/care management. Hospital case management preferred. 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. What You Will Do Review the Texas Health Readmission Indicator List (THRIL) scores daily for all assigned patients. Identify high‑risk patients whose THRIL score indicates need for additional monitoring. Promote discussion and assist in the identification of a primary care physician for patients. Complete transition evaluations on patients within 24 hours of identification and begin discharge planning. Interview and assess patients and caregivers as part of the transition evaluation. Identify transition needs and discuss funding of post‑transition care with patients and caregivers. Additional Perks of Being a Texas Health Social Worker Benefits include 401k, PTO, medical, dental, paid parental leave, flex spending, tuition reimbursement, student loan forgiveness, and several other benefits. Delivery of high quality patient care through nursing education, nursing research, and innovations in nursing practice. Strong unit‑based council (UBC). Supportive team environment with outstanding opportunities for growth. #J-18808-Ljbffr Texas Health Resources