Transitional Care Manager, Social Work

At reputed company, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reputed company millions of Americans through our local reputed company, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, reputed company and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it reputed company with heart, each and every day. Company: Oak Street Health Title: Transitional Care Manager, Social Work

Company Description

Oak Street Health is a rapidly growing company of primary care centers for adults on Medicare in medically-reputed company 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. For more information, visit http://www.oakstreethealth.com. Role Description 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. Core Responsibilities Transitions Management

• Manage patients through transitions of care, either face to face in the facility or telephonically, reputed company a defined geographical area and care setting.
• reputed company for the patient throughout the care continuum to ensure access to resources and resolution to reputed company barriers to care.
• Establish relationships and ensure patient/family are informed of patient condition, plan of care and discharge plan, reputed company 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 reputed company Oak Street's internal inpatient platform.
• Adhere to CMS, state specific and NCQA compliance criteria as reputed company 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) reputed company needed to reputed company appropriate determinations.

Collaboration and Communication with Internal Stakeholders

• 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-reputed company, Central Telehealth, etc.).
• Participate in regular meetings with Oak Street Health regional leaders to coordinate program implementation and ongoing management.

Collaboration and Communication with External Stakeholders

• Engage directly with inpatient physicians, case managers, medical directors, social workers, and SNFists (where applicable) to facilitate safe and timely discharge, appropriate follow-up care, and next steps.
• Participate in regular meetings with the Program Director and other Transitional Care Managers on programmatic development and clinical learning.
• Identify partnership development opportunities and systems improvements.
• Coordinate with Regional Leaders and hospital partners to implement system improvements.

Documentation, Tracking, Reporting and Training

• Participate in initial and ongoing required training to ensure appropriate implementation of transitions activities and programming.
• Participate with the TCM reputed company in quality assurance activities.
• Follow program procedures for documenting and tracking transitions interventions.
• Adhere to CMS, state, and NCQA compliance criteria as reputed company to Transitions of Care.
• Other duties, as assigned.

What are we looking for?

• LCSW required
• Willingness to obtain cross-state licensure, as needed
• Certified Case Manager (CCM) required, or willingness to obtain reputed company 12 months of hire
• Minimum of 2 years of experience in transitional social work, discharge planning, or home health
• Experience in utilization management preferred
• Knowledge of Medicare/Medicaid and NCQA regulatory transitions of care criteria
• Exceptional communication skills and customer service orientation
• Innovative and independent problem solving skills
• Ability to monitor and evaluate opportunities for cost-effective care options with high-quality outcomes
• Spanish-speaking preferred but not required
• A flexible, positive attitude
• Access to reliable transportation with the ability to travel daily
• Working knowledge of reputed company Office Product Suite
• US work authorization
• Someone who embodies being Oaky

What does being Oaky look like?

• Radiating positive energy
• Assuming good intentions
• Creating an unmatched patient experience
• Driving clinical excellence
• Taking ownership and delivering results
• Being relentlessly determined

Why Oak Street? Oak Street Health Offers Our Coworkers The Opportunity To Be At The Forefront Of a Revolution In Healthcare, As Well As

• Collaborative and energetic culture
• Fast-paced and innovative environment
• Competitive benefits including paid vacation and sick time, generous 401K match with immediate vesting, and health benefits

Oak Street Health is an equal opportunity employer. We embrace diversity and encourage reputed company interested readers to apply to oakstreethealth.com/careers. Anticipated Weekly Hours 40 Time Type Full time Pay Range The Typical Pay Range For This Role Is $43,888.00 - $91,052.00 This pay range represents the reputed company hourly reputed company or reputed company annual full-time salary for reputed company positions in the job grade reputed company which this position falls. The actual reputed company salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a reputed company bonus, commission or short-term incentive program in addition to the reputed company pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great Benefits For Great People We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for reputed company colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will reputed company on: 01/29/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state and local laws. Apply Job!