Title
Integrated Transitional Care Manager, MSW
Schedule : M-F, : am : pm, REMOTE
Pay : $
DESCRIPTION
Under the direction of the Supervisor, Integrated Transitional Care, this position focuses on a person-centered model of care which takes in to account the Member's medical, behavioral, and social needs.
The Integrated Transitional Care (ITC) Team will provide services to all Medi-Cal Members transitioning to and from hospitals, institutions, other acute care facilities, and skilled nursing facilities to home or community-based settings.
This position is responsible for serving as a resource for Members and Providers for care coordination and discharge planning, collaborating with both internal and external partners to connect Members with appropriate services to ensure a seamless transitions of care experience.
The ITC MSW will provide transitional care services to Members transitioning from one care setting to the next. This may include meeting with the Member face to face to conduct assessment and evaluation of transitional care needs both in the hospital as well as in the home setting.
Assist Members with care coordination needs, including, but not limited to the following :
a. Perform facility and home visits as needed to engage Member and obtain Member history and other information to assist in discharge planning.
b. Develop a discharge plan in collaboration with the Integrated Transitional Care Team and the facility.
c. Communicate discharge plan with Member, approved family or caregiver and other Members of the care team.
d. Coordinate with internal and external health partners, county agencies, and community-based organizations to support Members' comprehensive care needs.
e. Assist Member with resources such as IHSS, CBAS, MSSP, behavioral health, including substance abuse treatment, assistive devices, etc.
f. Refer Member, as appropriate, for Community Supports Services provided under CalAIM (, Medically Tailored Meals, Housing Transition and Navigation, Asthma Remediation, etc.
- Model the highest ethical behavior in care for Members, as well as in relationships with co-workers, Leaders, internal, and external partners.
- Advocate for Members to receive the highest quality care, in a timely manner, within the company's network by making appropriate referrals to Behavioral Health, Enhanced Care Management, and Complex Care Management.
- Support Member through all care transitions by providing transitional care services such as Member outreach, face to face visits, providing care coordination, linkage to resources, and facilitating Member self-efficacy and self-management.
- Participate in Integrated Transitional of Care Team meetings, Interdisciplinary Care Conferences, and any other meetings as required.
- Model continuous quality improvement philosophy and engage in quality improvement initiatives and projects.
- Model supportive and collaborative relationships with Members, co-workers, facility partners, and community providers.
- Engage in all company Team Member training and comply with all company policies.
REQUIREMENTS
- Minimum of three () years of experience in a Behavioral Health / Medical Social Work setting. Experience in motivational interviewing and / or other evidenced-based communication strategies
- Master's degree in social work from an accredited institution required
- Must have a valid California Driver's License
- Familiarity with Managed Care and discharge planning is required
- Knowledgeable and skilled in evidenced-based communication such as Motivational Interviewing, or similar empathy-based communication strategies
- Understanding of and sensitivity to multi-cultural communities
- Deep understanding and knowledge of mental health and substance use conditions, including both acute and chronic management.
Awareness of the impact of unmitigated bias and judgement on health; commitment to addressing both
Must have knowledge of whole health and integrated principles and practices
INDH
LCSW, Integrated Transitional Care Manager 24-00785
The ITC LCSW will act as a care manager for care transitions and collaborate with the ITC team members to provide transitional care services to Members transitioning from one care setting to the next. Integrated Transitional Care Manager, LCSW or LMFT. Under the direction of the Supervisor, Integrat...
Integrated Transitional Care Nurse, RN 24-00774
Integrated Transitional Care Nurse, RN. Join our dynamic team in the Integrated Transition Care Department! Under visionary leadership, you'll collaborate with hospitals and Independent Physician Associations to deliver continuous, quality healthcare to our high-risk Members. As the Integrated Trans...
Integrated Transitional Care Nurse, RN 24-00774
Integrated Transitional Care Nurse, RN. Join our dynamic team in the Integrated Transition Care Department! Under visionary leadership, you'll collaborate with hospitals and Independent Physician Associations to deliver continuous, quality healthcare to our high-risk Members. As the Integrated Trans...
Behavioral Health Care Manager, Licensed 24-00789
Care Management is broadly defined, and can include outreach and engagement to members, engaging members in skilled therapeutic interactions to promote health behaviors, coordination of care, resource linkages, working with other professionals and organizations in the community to ensure quality of ...
Behavioral Health Care Manager, Licensed 24-00789
Behavioral Health Care Manager . Join our clients dedicated team under the guidance of the Behavioral Health and Care Management Leadership, where you will deliver exceptional care management services to our members. Your expertise will support smooth care transitions, ensuring members receive the r...
Care Manager, RN 24-00626
Under the general supervision of the Manager and direct supervision of the Care Management Supervisor, this position is responsible for working effectively with the Integrated Care Team to provide high quality, effective care management to company members. Care management is broadly defined, and can...
Integrated Transitional Care Nurse, RN
Join our dynamic team in the Integrated Transition Care Department! Under visionary leadership, you’ll collaborate with hospitals and Independent Physician Associations to deliver continuous, quality healthcare to our high-risk Members. As the Integrated Transitional Nurse, Rn, you’ll lead risk asse...
Mental Health Therapist (LCSW. LMFT, LPCC) - La Verne, CA
LifeStance is a national provider of mental healthcare services focused on evidenced-based, medically driven treatment services for children, adolescents and adults suffering from a variety of mental health issues in an outpatient care setting, both in-person at its clinics nationwide and through it...
Regional Mass Care Manager
As a Regional Mass Care Manager, you will be responsible for regionwide mass care planning to ensure essential disaster services, including feeding, sheltering, household pets, distribution of emergency supplies and reunification, are available and delivered in a seamless fashion. We take care of yo...
Front Office Patient Care Coordinator (Multi-Specialty)
Provides administrative support to the providers and interacts with patients by scheduling patient appointments in tandem with the provider availability, interacts with patients in person and on the phone, answers clinic phone, greets patient at check-in, collects patient information, updates/mainta...