Lead Transitional Care Manager (RBE) LCSW Required
Description
Company: Oak Street Health
Title: Lead Transitional Care Manager *LCSW Required , preferred: IN, IL, MI or PA*
Company Description
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. 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 (TCM) Lead is an integral part of the team. The OSH Transitions of Care program focuses on providing a multi-disciplinary connection between OSH Care Navigation, Utilization Management, facility, local care teams and patient/family. The TCM Lead is responsible for providing day-to-day oversight and support to TCMs and executing the Transitions of Care program goals, which include ensuring high-quality, patient-centered care; preventing avoidable readmissions; and managing efficient resource utilization and improving patient and provider satisfaction.
Core Responsibilities:
Supervise the Transitional Care Managers in assigned markets, including clinical oversight of the following daily operations and metrics:
Transitions management: Evaluating patient status through clinical assessments and medical record review; inpatient and post-acute discharge planning; reconciling medication lists on behalf of the primary care provider (PCP); and scheduling post-discharge visits with the PCP
Coordination with utilization management: Partnering with UM to review medical and payer records to ensure appropriate length of stay and identify and address any barriers to discharge
Collaboration and communication with internal stakeholders: Coordinating with internal stakeholders (e.g., care team, social work, behavioral health, utilization management, Hard-to-Reach, Central Telehealth, etc.) to promote patient outreach and engagement and identify and address patient needs
Collaboration and communication with external stakeholders: Engaging directly with inpatient physicians, case managers, medical directors, social workers, and hospitalists/SNFists (where applicable) to facilitate safe and timely discharge and appropriate follow-up care and identifying partnership development opportunities and systems improvements
Documentation, tracking, reporting and training: Documenting and monitoring transitions activities and effectiveness; participating in regular trainings; evaluating quality and impact of transitions activities
Balance staff caseloads and provide coverage and support as needed.
Maintain up to 50% of a panel, depending on the clinical scope of the transitions program in specific regions.
Monitor team and individual performance and coach team members to improve performance when appropriate.
Provide direct or supporting efforts in the hiring and training of Transitional Care Managers in assigned regions.
Assist with the implementation of transitional care activities and programming.
Execute effective collaboration between multi-disciplinary teams, including but not limited to: OSH Care Navigation, Utilization Management, facilities, local care teams and patient/family.
Adhere to CMS, state specific and NCQA compliance criteria as related to Transitions of Care.
Monitor OSH data related to patient cost, admissions, post-discharge appointment completion and health outcomes to help guide and direct Transitions of Care program initiatives and goals.
Other duties as assigned.
What are we looking for?
An active RN or LCSW license within the state of practice in good standing
Cross-state licensure preferred, or willingness to obtain cross-state licensure
Nurse Case Management Credentialing (RN-BC) or Certified Case Manager (CCM) required, or willingness to obtain within 12 months of hire
Minimum 2 years of direct supervisory experience
Minimum of 2 years of experience in transitional care nursing, discharge planning or home health
Experience in utilization management
Knowledge of Medicare/Medicaid and NCQA regulatory transitions of care criteria
Strong clinical and assessment skills
Outstanding verbal and written communication skills
Ability to work independently and maintain flexibility in a fast-paced, start-up environment
Ability to analyze data and use it to improve care delivery
Self-starter with a high level of accountability and responsibility for the outcome of care
Highly organized and able to manage multiple priorities appropriately
Independent problem-solving skills
Able to work collaboratively and build enduring relationships with providers, patients and the multidisciplinary team
A flexible, positive attitude
Access to reliable transportation with the ability to travel daily
Ability to supervise home visits (virtually or in person) as needed
Working knowledge of Microsoft 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 scrappy
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 all interested readers to apply to oakstreethealth.com/careers.