Transitional Care Manager Social Worker (License Required))
Core
Manage patients through transitions of care to prevent avoidable readmissions and ensure efficient resource utilization in primary care settings.
Role type
Transitional Care Manager Social Worker
Builds
Post-acute care plans and discharge coordination for Medicare patients
Domain
Healthcare / Social Work / Medicare
Deliverable
client delivery
Required skills
Transitional social work, discharge planning, home health, utilization management, Medicare/Medicaid regulatory criteria, medication reconciliation, care continuum advocacy
Preferred skills
Cross-state licensure, Spanish language, innovative problem solving
Technologies
Microsoft Office Product Suite
Responsibilities
Manage patient transitions face-to-face or telephonically; coordinate with utilization management for discharge determinations; collaborate with internal and external stakeholders for safe discharge; document and track interventions; adhere to CMS and NCQA compliance criteria.
Seniority
Mid-level, hands-on IC