Transitional Care Leader – Social Work

Oak Street Health, part of CVS Health; Indianapolis (IN); On-site; USD 44,000 - 91,000; Full time

Benefits offered by this job

Paid vacation

Sick time

401K with immediate vesting

Health benefits

Job summary

Oak Street Health is seeking a Transitional Care Manager, Social Work to lead patient-centered transitions across care settings. You will coordinate discharge planning, advocate for patients, and ensure timely follow-up with PCPs, hospitals, SNFs, and Oak Street clinics.

The role emphasizes collaboration with care teams and adherence to CMS/NCQA criteria. Requirements include Indiana LSW or LCSW, CCM within 12 months, and 2+ years in transitional social work or discharge planning.

Qualifications

• Indiana LSW or LCSW required.
• Willingness to obtain cross-state licensure as needed.
• CCM certification required, or willingness to obtain within 12 months.
• Minimum of 2 years of experience in transitional social work, discharge planning, or home health.
• Experience in utilization management preferred.

Responsibilities

• Manage transitions of care for patients, in facility or telephonically, within defined areas.
• Advocate for patients across the care continuum to secure resources and resolve barriers.
• Coordinate discharge planning, ensure patient/family informed of plan and follow-up.
• Identify opportunities to improve workflows and partnerships for higher quality care.
• Maintain accurate patient records across care transitions in Oak Street’s inpatient platform.
• Adhere to CMS, state, and NCQA compliance criteria for transitions of care.

Skills

Discharge planning

Transitions of care

Care coordination

Communication skills

Education

Licensed Social Worker (LSW) / LCSW

Certified Case Manager (CCM) within 12 months

Tools

Microsoft Office

Job description

Oak Street Health is seeking a Transitional Care Manager, Social Work to lead patient-centered transitions across care settings. You will coordinate discharge planning, advocate for patients, and ensure timely follow-up with PCPs, hospitals, SNFs, and Oak Street clinics.

The role emphasizes collaboration with care teams and adherence to CMS/NCQA criteria. Requirements include Indiana LSW or LCSW, CCM within 12 months, and 2+ years in transitional social work or discharge planning.