Transitional Care Manager, Social Worker (License Required)

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

📋 Description

• Oversee patient transitions of care, whether in-person at the facility or via telephone, within a specified geographical area and care setting.

• Serve as an advocate for the patient throughout the entire care continuum to facilitate access to resources and resolve any barriers to care.

• Build relationships and ensure that patients and their families are well-informed about the patient's condition, care plan, discharge plan, instructions for discharge, medication reconciliation, the rationale behind Utilization Management decisions, any related financial information, potential LTC transitions (if applicable), and the significance of prompt follow-up with the PCP after discharge.

• Identify opportunities for enhancing program workflows, fostering internal and external collaborations, and improving the quality of patient care.

• Keep real-time and precise records of patient status during care transitions using Oak Street's internal inpatient platform.

• Comply with CMS, state-specific, and NCQA compliance standards pertaining to Transitions of Care.

• Collaborate with the Utilization Management team to examine medical and payer records to ensure appropriate lengths of stay and detect any discharge barriers.

• Take part in routine inpatient and post-acute rounding calls with Care Navigation and Utilization Management teams to evaluate patient status and formulate suitable discharge plans.

• Support the Utilization Management team by accessing external medical record information (if available) as needed to make informed decisions.

• Work alongside other transitions team members (e.g., Transitional Care Managers - RN and Transitional Care Coordinators) to guarantee safe discharges and timely follow-ups.

• Communicate and coordinate with internal stakeholders to identify and address patient needs (e.g., care team, social work, behavioral health, utilization management, Hard-to-Reach, Central Telehealth, etc.).

• Attend regular meetings with Oak Street Health regional leaders to facilitate program implementation and ongoing management.

• Engage directly with inpatient physicians, case managers, medical directors, social workers, and SNFists (if applicable) to promote safe and timely discharges, appropriate follow-up care, and next steps.

• Participate in initial and ongoing mandatory training to ensure effective execution of transitions activities and programming.

• Adhere to program procedures for documenting and tracking transitions interventions.

• Perform other duties as assigned.

⛳️ Requirements

• LSW/LCSW in PA is mandatory.

• Willingness to obtain cross-state licensure, as required.

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

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

• Experience in utilization management is preferred.

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

• Outstanding communication skills and a strong customer service focus.

• Innovative and independent problem-solving abilities.

• Capability to assess and evaluate opportunities for cost-effective care options with quality outcomes.

• Spanish-speaking is preferred but not mandatory.

• Access to reliable transportation with the capacity to travel daily.

• Proficient in using Microsoft Office Product Suite.

• Authorization to work in the US.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Paid time off.

• Wellness programs.

• Retirement savings options.