Transitional Care Manager – Social Work (LSW/LCSW CCM)

CVS Health; Indiana (PA); Hybrid; USD 44,000 - 91,000; Full time

Job summary

Oak Street Health is seeking a Transitional Care Manager, Social Work, to lead care transitions for patients across acute and post-acute settings. You will coordinate with care teams, clinicians and families to ensure timely follow‑ups, prevent readmissions, and optimize patient outcomes.

The role emphasizes interdisciplinary teamwork, CMS/NCQA compliance, and strong communication. Indiana-based licensure and CCM are required, with cross‑state licensure possible.

Qualifications

• Indiana LSW or LCSW required.
• Certified Case Manager (CCM) 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.
• US work authorization.

Responsibilities

• Manage patients through transitions of care, face to face or telephonically within a defined geographical area and care setting.
• Advocate for the patient to ensure access to resources and resolution to barriers to care.
• Establish relationships and inform patient/family about condition, plan of care and discharge instructions.
• Identify opportunities for improved program workflows and partnerships to enhance care quality.
• Maintain real-time records of patient status through care transitions in Oak Street Health systems.
• Adhere to CMS, state, and NCQA criteria related to Transitions of Care.

Skills

LSW/LCSW license

CCM certification

Discharge planning experience

Spanish-speaking (preferred)

Travel availability

Job description

Oak Street Health is seeking a Transitional Care Manager, Social Work, to lead care transitions for patients across acute and post-acute settings. You will coordinate with care teams, clinicians and families to ensure timely follow‑ups, prevent readmissions, and optimize patient outcomes.

The role emphasizes interdisciplinary teamwork, CMS/NCQA compliance, and strong communication. Indiana-based licensure and CCM are required, with cross‑state licensure possible.