Transitional Care Manager Social Worker — PA license required

Role Description:

Oak Street Health takes a team-based approach to providing outstanding patient care. The Transitional Care Manager — SW (TCM-SW) is an integral part of the team. The TCM-SW is the primary member of the Oak Street care team and facilitator of interdisciplinary collaboration and care continuity across care settings and systems, empowering the patient and/​or caregiver to play an active and informed role in post-acute care plan execution. The TCM-SW’s role is to provide information and support for the patient in identifying and addressing problems and building relationships with providers and care teams in various sites of care (e.g., ED, hospital, SNF, Oak Street Health clinics). 

This role prioritizes the relationship with the patient/​family; providing high-quality, patient-centered care; preventing avoidable readmissions; and managing efficient resource utilization.

Core Responsibilities:

Transitions Management

• 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.

Coordination with Utilization Management

• 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.

Collaboration and Communication with Internal Stakeholders

• 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.

Collaboration and Communication with External Stakeholders

• 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 regular meetings with the Program Director and other Transitional Care Managers on programmatic development and clinical learning.

• Identify partnership development opportunities and systems improvements.

• Coordinate with Regional Leaders and hospital partners to implement system improvements.

Documentation, Tracking, Reporting and Training

• Participate in initial and ongoing required training to ensure appropriate implementation of transitions activities and programming. 

• Participate with the TCM Lead in quality assurance activities.

• 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.

What are we looking for?

• Masters in Social Work required 

• LSW or local equivalent 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

• A flexible, positive attitude

• Access to reliable transportation with the ability to travel daily

• Working knowledge of Microsoft Office Product Suite

• US work authorization

• Someone who embodies being ​‘Oaky’