Transitional Care Manager, Social Worker (License Required)

Role Overview

• Manage patients through transitions of care, either face to face in the facility or telephonically, within a defined geographical area and care setting.
• Advocate for the patient throughout the care continuum to ensure access to resources and resolution to all barriers to care.
• Establish relationships and ensure patient/family are informed of patient condition, plan of care and discharge plan, all discharge instructions, medication reconciliation; rationale of Utilization Management determinations and any financial information associated with such, potential for LTC transition (if applicable) and importance of timely PCP follow-up following discharge.
• Identify opportunities for improved program workflows, increased internal and external partnerships, and higher quality patient care.
• Maintain real-time and accurate records of patient status through care transitions within Oak Street's internal inpatient platform.
• Adhere to CMS, state specific and NCQA compliance criteria as related to Transitions of Care.
• Coordinate with the Utilization Management team to review medical and payer records to ensure appropriate length of stay and identify any barriers to discharge.
• Participate in regular inpatient and post-acute rounding calls with Care Navigation and Utilization Management teams to help determine patient status and appropriate discharge plan.
• Assist Utilization Management team with access to external medical record information (if available) when needed to make appropriate determinations.
• Collaborate with other transitions team members (e.g., Transitional Care Managers
• RN and Transitional Care Coordinators) to ensure safe discharge and timely follow up.
• 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.).
• Participate in regular meetings with Oak Street Health regional leaders to coordinate program implementation and ongoing management.
• Engage directly with inpatient physicians, case managers, medical directors, social workers, and SNFists (where applicable) to facilitate safe and timely discharge, appropriate follow-up care, and next steps.
• Participate in initial and ongoing required training to ensure appropriate implementation of transitions activities and programming.
• Follow program procedures for documenting and tracking transitions interventions.
• Other duties, as assigned.

Requirements

• LSW/LCSW in PA required
• Willingness to obtain cross-state licensure, as needed
• Certified Case Manager (CCM) required, or willingness to obtain within 12 months of hire
• Minimum of 2 years of experience in transitional social work, discharge planning, or home health
• Experience in utilization management preferred
• Knowledge of Medicare/Medicaid and NCQA regulatory transitions of care criteria
• Exceptional communication skills and customer service orientation
• Innovative and independent problem solving skills
• Ability to monitor and evaluate opportunities for cost-effective care options with high-quality outcomes
• Spanish-speaking preferred but not required
• Access to reliable transportation with the ability to travel daily
• Working knowledge of Microsoft Office Product Suite
• US work authorization.

Benefits

• Medical, dental, and vision coverage
• Paid time off
• Wellness programs
• Retirement savings options