Social Worker, Care Transition Manager, PRN, Days
Texas Health Resources
Date: 4 days ago
City: Flower Mound, TX
Contract type: Full time
25000600
Care Transition Social Worker
What You Will Do
Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner:
Completes Transition Evaluations and collects Social Determinants of Health (SDOH) data on patients within 48 hours of identification and begins discharge planning. Assesses and interviews patient and caregivers as part of this evaluation and as needed.
Reviews the Risk of Unplanned Readmission (RUR ) scores daily for all assigned patients.
Assists in the identification of a primary care physician (PCP) for patients without a PCP and attempts to schedule follow up appointments with either a PCP, specialist, clinic, visiting physician or other transitional care visit prior to discharge.
Identifies transition needs and discusses funding of post-transition care with patients and caregivers.
Additional Perks Of Being a Texas Health Employee
99-bed facility with more than 500 physicians on our medical staff who practice a full range of specialties. In addition to our modern facility and high-tech equipment, we have a dedicated team of physicians and staff who go above and beyond to provide the highest quality medical care to every patient who comes through our door. As a result, we’ve been recognized as the best provider of healthcare services by our patients, peers and the community numerous times.
If you’re ready to join us in our mission to improve the health of our community, then let’s show the world how we’re even better together!
Learn More About Our Culture, Benefits, And Recent Awards.
Do you still have questions or concerns? Feel free to email your questions to [email protected]
Care Transition Social Worker
What You Will Do
Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner:
Completes Transition Evaluations and collects Social Determinants of Health (SDOH) data on patients within 48 hours of identification and begins discharge planning. Assesses and interviews patient and caregivers as part of this evaluation and as needed.
Reviews the Risk of Unplanned Readmission (RUR ) scores daily for all assigned patients.
Assists in the identification of a primary care physician (PCP) for patients without a PCP and attempts to schedule follow up appointments with either a PCP, specialist, clinic, visiting physician or other transitional care visit prior to discharge.
Identifies transition needs and discusses funding of post-transition care with patients and caregivers.
Additional Perks Of Being a Texas Health Employee
- Benefits include 401k, PTO, medical, dental, Paid Parental Leave, flex spending, tuition reimbursement, Student Loan Repayment Program as well as several other benefits.
- Delivery of high quality of patient care through nursing education, nursing research and innovations in nursing practice.
- Strong Unit Based Council (UBC).
- A supportive, team environment with outstanding opportunities for growth.
99-bed facility with more than 500 physicians on our medical staff who practice a full range of specialties. In addition to our modern facility and high-tech equipment, we have a dedicated team of physicians and staff who go above and beyond to provide the highest quality medical care to every patient who comes through our door. As a result, we’ve been recognized as the best provider of healthcare services by our patients, peers and the community numerous times.
If you’re ready to join us in our mission to improve the health of our community, then let’s show the world how we’re even better together!
Learn More About Our Culture, Benefits, And Recent Awards.
Do you still have questions or concerns? Feel free to email your questions to [email protected]
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