Case Manager (Transitional Care Facilities)

MOH Holdings (Singapore); Singapore; On-site; SGD 60,000 - 90,000; Full time

Job summary

MOH Holdings (Singapore) is seeking a Case Manager/Assistant Case Manager to act as a care connector for Transitional Care Facility (TCF) patients. You will collaborate with the multidisciplinary care team to plan discharge, ensuring safe, timely transitions to long-term care arrangements in the community.

You will support patients with psychosocial needs, including financial counselling, work with MSWs to coordinate post-discharge services, and participate in audits and quality improvement

Qualifications

• Bachelor’s or Master’s degree in Social Work from an accredited institution.
• At least 5 years of relevant medical social work experience, preferably in healthcare.
• Excellent communication, empathetic, and culturally sensitive.
• Ability to work in fast-paced, multidisciplinary teams.
• Strong problem-solving and decision-making abilities.
• Experience with discharge planning and crisis intervention.

Responsibilities

• Work with MSWs to conduct psychosocial assessments for patients and their families to identify emotional, social, and environmental challenges impacting their health and recovery.
• Develop care plans with MSWs and healthcare team addressing social, psychological, and financial needs on admission into TCFs.
• Develop and implement discharge plans coordinating post-care services, home support, rehab, and community resources; ensure patients and families understand discharge instructions and follow-up care.
• Identify and connect patients with external resources such as financial aid, community services, counselling, and support groups; facilitate access to government and NGO programs.
• Maintain accurate confidential records of patient interactions, assessments, care plans, and progress; prepare reports for case management and audits.
• Participate in multidisciplinary team meetings and contribute to comprehensive care plans; collaborate with doctors, nurses, therapists to optimise outcomes.
• Exercise sound professional judgement to resolve care transition barriers, escalate systemic issues when needed.
• Participate in audits, service reviews and quality improvement projects related to transitional care and case management.
• Ensure case management practices comply with policies, standards and regulatory requirements.

Skills

Interpersonal skills

Empathy

Crisis intervention

Discharge planning

Team collaboration

Cultural competency

Education

Bachelor’s or Master’s degree in Social Work (BSW/MSW)

Job description

The Case Manager/ Assistant Case Manager will be a care connector for Transitional Care Facilities (TCF) patients. He/she will work with the multidisciplinary care team to assist with the discharge care planning of patients to ensure that they transit out of the TCFs for their long-term care arrangements. He/she will work closely with the Medical Social Workers (MSWs) to provide the patients with psychosocial support, including financial counselling for patients. He/she plays a critical role in ensuring safe, timely, and coordinated transitions of care for patients in TCFs, enabling sustainable long-term care arrangements in the community and reducing avoidable care delays and readmissions.

Job Responsibilities:

• Work with MSWs to conduct psychosocial assessments for patients and their families to identify emotional, social, and environmental challenges impacting their health and recovery.
• Work with the MSWs and / or healthcare team to develop care plans that address the social, psychological, and financial needs of patients upon admission into TCFs.
• Develop and implement discharge plans that include the coordination of post-care services, home support, rehabilitation, and community resources. Ensure patients and families understand discharge instructions and follow-up care.
• Identify and connect patients with external resources such as financial aid, community services, counselling, and support groups. Facilitate access to government and non-governmental programs that assist with medical, psychological, and financial needs.
• Maintain accurate and confidential records of patient interactions, assessments, care plans, and progress. Prepare reports for case management, and institutional audits.
• Participate in multidisciplinary team meetings and contribute to the development of comprehensive care plans. Collaborate with healthcare professionals, including doctors, nurses, and therapists, to optimise patient outcomes.
• Exercise sound professional judgement in resolving care transition barriers, particularly for complex cases involving multi-agency coordination, family dynamics or significant financial and psychosocial needs, and elevate systemic issues to management where necessary.
• Participate in audits, service reviews and quality improvement projects related to transitional care and case management. Identify recurring discharge barriers and contribute to service improvement initiatives to enhance patient flow and care integration.
• Ensure that case management practices comply with institutional policies, professional standards and relevant regulatory requirements.

Requirements:

• A Bachelor’s or Master’s degree in Social Work (BSW/MSW) from an accredited institution.
• Relevant Experience - Minimum of 5 years of relevant experience in medical social work, preferably in a healthcare or hospital setting is preferred. Experienced in patient and family counselling, crisis intervention, and discharge planning.
• Personal Characteristic and Behaviour - Strong knowledge of medical social work principles, healthcare systems, and community resources in Singapore. Strong problem-solving, critical thinking, and decision-making skills. Compassionate, empathetic, and sensitive to the diverse needs of patients.
• Excellent interpersonal and communication skills with the ability to empathise and build trust with MSWs, patients and families.
• Ability to work in a fast-paced, multidisciplinary team environment.
• Strong cultural competency and understanding of Singapore’s diverse community.
• Ability to handle emotionally charged situations and maintain professional boundaries.