Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner:
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.
Facilitates care conferences for complex transitions, placement and palliative care needs.
Serves as a point of contact for all identified stakeholders. 40%
Ensures patients are provided post-acute options based on clinical necessity and patient choice while also considering the payor source:
Serves as a content expert regarding payor information. Educates the multidisciplinary team, patients and caregivers regarding payor requirements and barriers.
Communicates with payors as needed.
Proactively identifies patients who no longer meet continued stay criteria and communicates with the physician team.
Attempts to schedule PCP, specialist or clinic follow up appointments for patients. 20%
Responsible for compliance with documentation guidelines and regulatory agency requirements:
Complies with all documentation requirements and documents all activities in the electronic health record.
Adheres to compliance requirements for delivery of various documents (e.g. HINN, IMM, MOON letters).
Has a working knowledge of the following documents: Advanced Directives, Medical Power of Attorney, Application for Temporary Mental Health Treatment, and out-of-hospital Do Not Resuscitate.
Participates in Joint Commission and other survey readiness activities 20%
Serves as a content expert on the following:
Compliance requirements for delivery of HINN, second IMM and MOON letters
Potential denials, avoidable days, and alternate level of care days
Medical necessity, patient status and discharge criteria
Clinical review staff requirements and communications 20%

Education
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

Experience
3 Years in hospital/medical social work Pref and
1 Year discharge planning/care management Pref

Licenses and Certifications
LMSW - Licensed Master Social Worker Upon Hire Req Or
LCSW - Licensed Clinical Social Worker Upon Hire Req And
CPR - Cardiopulmonary Resuscitation Upon Hire Req And
ACM - Accredited Case Manager Upon Hire Pref Or
CCM - Certified Case Manager Upon Hire Pref Or
Other ANCC Upon Hire Pref

Skills
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

Supervision
Individual Contributor

ADA Requirements
Extreme Heat 1-33%
Extreme Cold 1-33%
Extreme Swings in Temperature 1-33%
Extreme Noise 1-33%
Working Outdoors 1-33%
Working Indoors 67% or more
Mechanical Hazards 1-33%
Electrical Hazards 1-33%
Explosive Hazards 1-33%
Fume/Odor Hazards 1-33%
Dust/Mites Hazards 1-33%
Chemical Hazards 1-33%
Toxic Waste Hazards 1-33%
Radiation Hazards 1-33%
Wet Hazards 1-33%
Heights 1-33%
Other Conditions 1-33%

Physical Demands
Light Work