All the benefits and perks you need for you and your family:

• Benefits from Day One
• Paid Days Off from Day One
• Student Loan Repayment Program
• Career Development
• Whole Person Wellbeing Resources
• Mental Health Resources and Support
• Debt-free Education (Certifications and Degrees without out-of-pocket tuition expense)
• Nursing Clinical Ladder Program

Our promise to you:

Joining Texas Health Huguley - AdventHealth is about being part of something bigger. Its about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. Texas Health Huguley - AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Texas Health Huguley- operates as a joint venture between Texas Health Resources and AdventHealth.

Schedule: Full-Time

Shift: Monday - Friday (8 hours per day flexible)

Location: 11801 South Fwy., Burleson, TX 76028

The community you'll be caring for:

• Our care for patients extend to the spiritual level by praying with patients and families and providing on call, 24 hours, 7 days a week Chaplains for spiritual support.
• Award winning facility and departments including Great Place to Work by Beckers Hospital Review and Gallup.
• Work with the latest technology and top experts including Daisy Award recipients while on our journey to Magnet status and Pathways designated.
• Designated Emergency Center of Excellence recognizing our facility as a high-performing emergency department
• Located about 10 minutes from downtown Fort Worth and near TCU in the award-winning school district, Burleson ISD which also provides a low-cost of living.

The role you'll contribute:

The Social Work Care Manager intervenes with patients who have complex psychosocial needs, require assistance with eligibility determination for social programs, funding sources and qualify for community assistance from a variety of special assistance programs and agencies, and/or require assistance with transitions of care or discharge planning. In addition, offer crisis intervention to patients and families with psychosocial needs and coordinates and facilitates the development of a discharge plan of care for high-risk patient populations. This role will receive referrals for individuals from at-risk populations from interdisciplinary team members (including physicians, RN Care Managers, staff nurses, and other members of the care team). The Social Work Care Manager, in collaboration with the patient/family, care manager nurses, nurses, physicians and the interdisciplinary team, ensures patient-centered care coordination through the continuum of care. The Social Work Care Manager ensures efficient and cost-effective care through appropriate resources monitoring and clinical care escalations. The Social Worker is under the general supervision of the Care Management Supervisor or Manager and is responsible for patient evaluations of post-hospital needs; development of a transition of care plans and initiation of the implementation of the transitions of care plans prior to the discharge of the patient. The Social Work Care Manager is responsible for optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety, readmission prevention and length of stay management. The Social Work Care Manager communicates daily with the interdisciplinary team during daily multidisciplinary rounds. Care coordination, discharge planning, transitions of care planning and are core competencies of this role. The Social Work Care Manager facilitates the collaborative management of patient care across the continuum, intervening to remove barriers to timely and efficient care delivery and reimbursement. The Social Work Care Manager provides education to nurses, physicians and the interdisciplinary team on issues related to utilization of resources, medical necessity, CMS CoP for Discharge Planning and care coordination. The Social Work Care Manager is knowledgeable of post-hospital care and services available to the patient including, but not limited to the following: Home Health, Infusion Services, Durable Medical Equipment, Palliative Care, Hospice, Outpatient Services, Transitions of Care Clinics, Transitional Care supportive programs and clinics, follow up appointments, Skilled Nursing Facilities, Rehabilitation Services and Facilities and Community-based Organizations. The Social Work Care Manager adheres to departmental and system goals, objectives, policies and procedures and ensures quality patient care and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

The value you'll bring to the team:

• Provides grief counseling, disease adjustment support, crisis intervention, goals of care planning support, and de-escalation services for patients as appropriate.
• Assesses patients and families wholistically for discharge planning needs in the inpatient, observation and/or emergency departments, including prior functioning, support systems, financial, and psychosocial in a timely fashion to avoid delays in discharge planning.
• Reviews the medical record, including medications, history and physical, labs, and progress notes and incorporates the clinical, social, and financial factors into the transition of care plan.
• Develops discharge plans with appropriate contingency plans throughout the hospital stay to ensure timely care coordination and progression of care, making arrangements for post-acute care services and facilities as well as community care for social needs.
• Leverages technology and follows standard work and best practices to communicate with post-acute care services and facilities to ensure patient care information is communicated for continuity of care, medical records are complete, and discharge reconciliation is accurate.
• Actively participates in multi-disciplinary rounds to review changes in patient status, progression and level of care, and discharge plans for all assigned patients to identify resources necessary at discharge and ensure a timely transition, escalating care delays to leadership as appropriate.

Qualifications

The expertise and experiences you'll need to succeed:

EDUCATION AND EXPERIENCE REQUIRED:

• Master's Required
• 4 Work Experience Required

EDUCATION AND EXPERIENCE PREFERRED:

• Licensed Social Worker (LSW) Preferred
• Clinical Social Worker License (LCSW) Preferred
• Certified Social Worker (CSW) Preferred
• Licensed Masters Social Worker - Advanced Practice (LMSW-AP) Preferred
• Licensed Master Social Worker (LMSW) Preferred
• Lic Baccalaureate SocialWorker (LBSW) Preferred

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.

Category: Case Management

Organization: Texas Health Huguley Hospital

Schedule: Full-time

Shift: 1 - Day

Req ID: 25034073

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.