Transitional Care Manager, Social Work – LSW or LCS Required

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee the management of patients during transitions of care, either in person at facilities or via telephone within a designated geographical area and care environment.

• Serve as an advocate for patients throughout the entire care continuum and work to eliminate barriers to care.

• Build and nurture relationships with patients, their families, healthcare providers, and care teams.

• Clearly communicate patient conditions, care and discharge plans, instructions, medication reconciliations, utilization management decisions, and financial information.

• Identify and implement opportunities to enhance workflows, partnerships, and the quality of patient care.

• Maintain up-to-date and accurate patient transition records in Oak Street’s internal inpatient platform.

• Comply with CMS, state-specific, and NCQA standards regarding transitions of care.

• Collaborate with Utilization Management to review patient records, evaluate length of stay, and identify barriers to discharge.

• Engage in inpatient and post-acute rounding calls.

• Work in conjunction with transitional care, care navigation, utilization management, social work, behavioral health, and other internal teams.

• Collaborate with inpatient physicians, case managers, medical directors, social workers, and SNFists to ensure safe discharge and follow-up care.

• Take part in meetings focused on program implementation, development, clinical learning, and system enhancements.

• Participate in training sessions and quality assurance initiatives.

• Document and track interventions related to patient transitions.

• Carry out additional duties as assigned.

⛳️ Requirements

• Valid Indiana LSW or LCSW is required.

• Must be willing to obtain cross-state licensure, if necessary.

• Certified Case Manager (CCM) certification is required, or the willingness to obtain it within 12 months of hire.

• A minimum of 2 years of experience in transitional social work, discharge planning, or home health is essential.

• Experience in utilization management is preferred.

• Familiarity with Medicare/Medicaid and NCQA regulatory criteria for transitions of care is necessary.

• Outstanding communication skills and a strong customer service orientation are essential.

• Must possess innovative and independent problem-solving abilities.

• Capability to monitor and assess opportunities for cost-effective care options that lead to high-quality outcomes is required.

• Spanish-speaking is preferred but not mandatory.

• Must demonstrate a flexible and positive attitude.

• Access to reliable transportation with the ability to travel on a daily basis is required.

• Proficiency with Microsoft Office Product Suite is necessary.

• US work authorization is mandatory.

• Ideal candidates will embody the Oaky spirit.

🏝️ Benefits

• Paid vacation and sick leave.

• Generous 401K matching with immediate vesting.

• Comprehensive medical coverage.

• Dental insurance available.

• Vision insurance provided.

• Paid time off.

• Options for retirement savings.

• Wellness programs available.

• Additional resources to support physical, emotional, and financial well-being.

• Eligibility for CVS Health bonus, commission, or short-term incentive programs.