Care Transition Social Worker


Plano, TX

What you'll be doing

Actively participates in daily patient care briefings and identifies patients appropriate for transition needs intervention. Reviews readmission risk predictor (rrp) scores daily for all assigned patients. Collaborates with interdisciplinary team to identify high risk patients whose RRP score may not have indicated appropriately. Ensures all assigned patients have an identified primary care physician (PCP). Exhausts all efforts in an attempt to assign. Identifies transition needs (including medications), develops transition plan within 24 hours of referral, and discusses funding of post-transition care with patients / caregivers; documents appropriately. Validates transition plan with Inter disciplinary team (physician, clinical nurse leader, nursing, etc.). Updates estimated transition date (etd) as needed. Educates interdisciplinary team and patients / caregivers regarding available post-acute care services and needs.

What your background should be

Minimum three years in hospital/medical social work required. Recent experience in acute care hospital discharge planning/care management (preferred). Licensed as LMSW. CPR certification within 30 days of hire (required). CPUR CPHQ, CCS, CPUM or CM certification (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.

Required Schooling / Training

Master degree in social work (required)

Who is the client company

This is a non-profit company that operates a network of hospitals.
If you are interested in this position, send your resume to