Transitional Care Manager, Social Work (LSW or LCS required)
Core
Manage patients through transitions of care to prevent avoidable readmissions and ensure safe discharge across various care settings.
Role type
Transitional Care Manager (Social Work)
Builds
Post-acute care plans and care continuity for Medicare patients in medically underserved communities.
Domain
Healthcare / Social Work / Medicare
Deliverable
client delivery
Required skills
Transitional social work, discharge planning, home health, utilization management, Medicare/Medicaid regulatory criteria, resource utilization management
Preferred skills
Utilization management, Spanish language
Technologies
Microsoft Office Product Suite
Responsibilities
Manage patients through transitions of care face-to-face or telephonically; Advocate for patients to resolve barriers to care; Coordinate with Utilization Management to review medical records and determine discharge plans; Collaborate with internal stakeholders (RN TCMs, Care Navigation) and external stakeholders (physicians, SNFists, hospital partners) to facilitate safe discharge; Maintain accurate records of patient status within internal platforms; Participate in quality assurance activities and program implementation meetings.
Seniority
Mid-level, hands-on IC