Transitional Care Manager - Social Worker - Pennsylvania Social Worker

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Company: Oak Street Health

Title: Transitional Care Manager, Social Worker (License required)

Location: Remote, must live in PA

Oak Street Health is a rapidly growing company of primary care centers for adults on Medicare in medically‑underserved communities where there is little to no quality healthcare. Oak Street's care is based on an entirely new model that is based on value for its patients, not on volume of services. The company is accountable for its patients' health, spending more than twice as long with its patients and taking on the risks and costs of their care.

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Oak Street Health takes a team‑based approach to providing outstanding patient care. The Transitional Care Manager – SW (TCM‑SW) is an integral part of the team. The TCM‑SW is the primary member of the Oak Street care team and facilitator of interdisciplinary collaboration and care continuity across care settings and systems, empowering the patient and/or caregiver to play an active and informed role in post‑acute care plan execution.

The TCM‑SW's role is to provide information and support for the patient in identifying and addressing problems and building relationships with providers and care teams in various sites of care (e.g., ED, hospital, SNF, Oak Street Health clinics). This role prioritizes the relationship with the patient/family; providing high‑quality, patient‑centered care; preventing avoidable readmissions; and managing efficient resource utilization.

• Manage patients through transitions of care, either face to face in the facility or telephonically, within a defined geographical area and care setting.
• Advocate for the patient throughout the care continuum to ensure access to resources and resolution to all barriers to care.
• Establish relationships and ensure patient/family are informed of patient condition, plan of care and discharge plan, all discharge instructions, medication reconciliation; rationale of Utilization Management determinations and any financial information associated with such, potential for LTC transition (if applicable) and importance of timely PCP follow‑up following discharge.
• Identify opportunities for improved program workflows, increased internal and external partnerships, and higher quality patient care.
• Maintain real‑time and accurate records of patient status through care transitions within Oak Street's internal inpatient platform.
• Adhere to CMS, state specific and NCQA compliance criteria as related to Transitions of Care.
• Coordination with Utilization Management – Coordinate with the Utilization Management team to review medical and payer records to ensure appropriate length of stay and identify any barriers to discharge.
• Participate in regular inpatient and post‑acute rounding calls with Care Navigation and Utilization Management teams to help determine patient status and appropriate discharge plan.
• Assist Utilization Management team with access to external medical record information (if available) when needed to make appropriate determinations.

• Collaborate with other transitions team members (e.g., Transitional Care Managers – RN and Transitional Care Coordinators) to ensure safe discharge and timely follow up.
• Communicate and coordinate with internal stakeholders to identify and address patient needs (e.g., care team, social work, behavioral health, utilization management, Hard‑to‑Reach, Central Telehealth, etc.).
• Participate in regular meetings with Oak Street Health regional leaders to coordinate program implementation and ongoing management.