Transitions of Care; TOC) Supervisor, RN, LCSW or LSW

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Aloha Care’s leadership empowers and engages its employees by recognizing outstanding job performance and collaboration. We share organization-wide updates during quarterly All Staff meetings. We encourage participation in volunteer and educational opportunities. We put a high value on honesty, respect, and trust-building. We encourage open-door, two-way, and frequent communication.

Aloha Care’s comprehensive benefits package includes low-cost medical, dental, drug and vision insurance, paid time-off, 401k employer contribution, referral bonus and pretax transportation and parking program.

The Opportunity:

The Transition of Care (TOC) Supervisor leads and supports the TOC team in coordinating safe, timely, and effective transitions for members discharged from inpatient settings back to the community. This role helps ensure members receive the support, education, referrals, and follow-up needed to reduce avoidable readmissions, improve post-discharge outcomes, and promote continuity of care.

The TOC Supervisor works under the direction of the Health Coordination Director, alongside the Health Coordination Managers, and is responsible for supervising day-to-day team activities, coaching staff, reinforcing workflows, monitoring productivity, supporting audit readiness, and serving as a subject matter expert for TOC processes. The role supports the TOC Program’s focus on safe, cost-effective, high-quality care after hospitalization and contributes to quality and value-based outcomes such as reduced 30-day readmissions, improved emergency department utilization, and improved care coordination for members with chronic conditions, behavioral health needs, and social determinants of health needs.

The TOC Supervisor collaborates with internal teams such as Health Coordination, Medical Management, Behavioral Health, and Quality, as well as external providers, community resources, members and their families and caregivers to support successful care transitions. The role requires strong leadership, communication, organization, critical thinking, and the ability to support staff performance while maintaining compliance with QUEST Integration, Medicare, CMS Model of Care, NCQA, contractual, regulatory, and quality requirements.

Primary

Duties & Responsibilities:

Transition of Care Program Supervision

• Supervises the TOC team and supports day-to-day operations of the Transitions of Care Program.
• Supports implementation of TOC workflows aligned with QUEST Integration, CMS Model of Care, NCQA Care Transitions requirements, and organizational goals.
• Provides guidance, coaching, mentoring, and training to TOC staff to support consistent, effective, and timely member outreach.
• Serves as a TOC subject matter expert for staff, internal departments, providers, and community partners.
• Assists the Health Coordination Director with workflow design, workflow redesign, staff education, performance monitoring, and process improvement.
• Reinforces team productivity, accountability, unity, flexibility, and adherence to established workflows.
• Supports the team in helping members understand discharge instructions, follow-up appointments, medications, next steps in care, warning signs, and available health plan or community resources.
• Promotes timely post-discharge outreach and care coordination for members transitioning from inpatient facilities, nursing facilities, other congregate settings, and community-based locations.
• Supports member transitions back to…