Transitional Care Manager, Social Work

CVS Health Corporation; United States; Remote; USD 70,000 - 100,000; Full time

Job summary

Oak Street Health seeks a Transitional Care Manager, Social Work to lead transitions of care for patients across hospital, SNF and home health settings. You will coordinate with care teams, advocate for patients, and ensure effective discharge planning and follow-up to reduce readmissions.

Requires Indiana LSW or LCSW and CCM certification, with at least 2 years in transitional social work, and willingness to obtain cross-state licensure if needed.

Qualifications

• Indiana LSW or LCSW required.
• 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.

Responsibilities

• Manage transitions of care for patients in defined geographic area and care settings.
• Advocate for patients to ensure access to resources and timely follow-up.
• Coordinate with internal teams to ensure safe discharge and follow-up care.
• Maintain records of patient status through transitions and ensure CMS/NCQA compliance.
• Engage with inpatient physicians, case managers, and care teams to optimize discharge planning.

Skills

Indiana LSW or LCSW

CCM

Discharge planning

Utilization management

Job description

Oak Street Health seeks a Transitional Care Manager, Social Work to lead transitions of care for patients across hospital, SNF and home health settings. You will coordinate with care teams, advocate for patients, and ensure effective discharge planning and follow-up to reduce readmissions.

Requires Indiana LSW or LCSW and CCM certification, with at least 2 years in transitional social work, and willingness to obtain cross-state licensure if needed.