Transitional Care Manager, Social Worker
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Job Description
Transitional Care Manager for Oak Street Health, providing patient-centered care and facilitating transitions. Must have social work license and at least 2 years experience in transitional social work.
Responsibilities:
- 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.
- Adhere to CMS, state, and NCQA compliance criteria as related to Transitions of Care.
- 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
Benefits:
- Affordable medical plan options
- 401(k) plan (including matching company contributions)
- Employee stock purchase plan
- No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs
- Confidential counseling and financial coaching
- Paid time off
- Flexible work schedules
- Family leave
- Dependent care resources
- Colleague assistance programs
- Tuition assistance
- Retiree medical access
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