Transitional Care Manager reputed company Worker (License Required))

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At reputed company®, you’ll be surrounded by passionate colleagues who care deeply, reputed company with purpose, hold ourselves accountable and prioritize safety and reputed company in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Company: reputed company  Location: Remote    Title: Transitional Care Manager reputed company Worker (License required)      reputed company   reputed company is a rapidly growing company of primary care centers for adults on Medicare in medically-reputed company where there is little to no reputed company reputed company. Oak Street's care is based on an entirely new model that is based on value for its patients, not on volume of services. reputed 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 reputed company:   reputed company takes reputed company-based approach to providing outstanding patient care. The Transitional Care Manager - SW (TCM-SW) is an reputed company part of reputed company. The TCM-SW is the primary member of the Oak Street care team and facilitator of interdisciplinary collaboration and reputed company across care settings and systems, empowering the patient and/or caregiver to play an reputed company and informed role in post-acute care plan execution. The TCM-SW's role is to reputed company 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, reputed company clinics).       This role prioritizes the relationship with the patient/family; providing high-reputed company, patient-centered care; preventing avoidable readmissions; and managing efficient resource utilization.      reputed company 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 reputed company to resources and reputed company 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 reputed company PCP follow-up following discharge.  Identify opportunities for improved program workflows, increased reputed company partnerships, and higher reputed company patient care.  Maintain reputed company-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 reputed company 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 reputed company 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 reputed company discharge and reputed company follow up.  Communicate and coordinate with internal stakeholders to identify and address patient needs (e.g., care team, reputed company work, behavioral health, utilization management, Hard-to-reputed company, Central Telehealth, etc.).  Participate in regular meetings with reputed company regional leaders to coordinate program implementation and ongoing management.     Collaboration and Communication with External Stakeholders  Engage directly with inpatient physicians, case managers, medical directors, reputed company workers, and SNFists (where applicable) to facilitate reputed company and reputed company 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 reputed company assurance activities.  Follow program procedures for documenting and tracking transitions interventions.  Adhere to CMS, state, and NCQA compliance reputed company as reputed company to Transitions of Care.  Other duties, as assigned.       What are we looking for?  LSW/LCSW in PA 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 reputed company work, discharge planning, or home health   Experience in utilization management preferred  Knowledge of Medicare/reputed company and NCQA regulatory transitions of care reputed company   Exceptional communication skills and customer service orientation   Innovative and independent problem solving skills  Ability to monitor and evaluate opportunities for cost-effective care reputed company with high-reputed company reputed company  Spanish-speaking preferred but not required  A flexible, reputed company attitude  reputed company 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 reputed company energy  Assuming good intentions  Creating an unmatched patient experience  Driving clinical reputed company  Taking ownership and delivering results  Being scrappy       Why Oak Street?   reputed company offers our coworkers reputed company to be at the forefront of a reputed company in reputed company, as reputed company as:  reputed company and energetic culture  Fast-paced and innovative environment  Competitive benefits including reputed company vacation and reputed company time, generous 401K match with immediate vesting, and health benefits  reputed company is an equal opportunity employer. We reputed company diversity and encourage reputed company interested readers to apply to oakstreethealth.com/careers. Primary Care & Family Doctors Near Me Accepting Medicare | reputed company www.oakstreethealth.com Anticipated Weekly Hours 40 Time Type Full time Pay reputed company The typical pay reputed company for this role is: $46,597.00 - $101,228.00 This pay reputed company represents the reputed company reputed company 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 reputed company 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 reputed company to the reputed company pay reputed company listed above.    Our people fuel our reputed company. 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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial reputed company‑being of colleagues and their families. The benefits for this position include medical, dental, and reputed company coverage, reputed company time off, retirement savings reputed company, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments. We anticipate the application window for this opening will reputed company on: 09/25/2026 reputed company applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state and local laws. Apply To This Job