Transition of Care Social Worker

5 months ago(8/15/2017 12:02 PM)
Job ID
# of Openings Remaining
Experience (Years)
Case and Disease Mgmt


Transitions of care from hospital to post-acute settings (including home) are high risk times for patients that often result in adverse events and readmissions.  The Alameda Alliance for Health has launched a new multidisciplinary Transitions of Care team focused on providing support, care coordination, and coaching/education for patients at increased risk of readmission.  The Transition of Care (TOC) Social Worker works under the direct supervision of the Manager, Transition of Care and is part of a team of TOC Nurses and TOC Pharmacists.  The TOC team is responsible for coordinating the care transition and follow-up from the acute hospital to home or facility for the initial 30 days post hospital discharge.  While the TOC Social Worker participates in all aspects of the transition of care process, the Social Worker’s fundamental role is to assess, educate, and link members to community and partner resources in order to empower the member to meet their health care needs and ensure coordination and continuity of care following discharge from the hospital.


  • Engage members while they are still in the hospital, introducing them to the program, consenting them, providing a comprehensive needs/risk assessment including mental health , and implementing a patient-centered care plan which includes a personal health record
  • Empower members to take an active role in their discharge planning and post-acute care by providing education, tools and support to foster self-management and to successfully respond to common problems that arise during transitions.
  • Use patient goals and values to help develop care plan. Discuss advanced care planning and advanced directives when appropriate.
  • Collaborate with the hospital providers and, case managers, PCPs, and other members of the care team to create and implement transition of care plans.
  • Consult with Medical Director, Concurrent Review team, and other AAH internal stakeholders to anticipate and coordinate discharge needs and prevent readmissions and/or inappropriate ED use
  • Utilize modalities of short/long term counseling including CBT, solution-focused counseling
  • Participate in evaluation of Transitions of Care work-flows and processes as part of continuous quality improvement work
  • Coordinate with family and caregivers as appropriate
  • Utilize guiding principles and practice strategies of Motivational Interviewing with patient and family caregivers
  • Provide telephonic or in-person counseling, teaching, and care coordination
  • Assess member’s baseline activation level for self-care
  • Utilize patient coaching techniques to build confidence and competence in the transitions of care plan as it relates to: medication management, follow-up appointments, knowledge of red flags related to their condition and how to respond
  • Schedule primary care follow up within 3-5 business days after hospital discharge; ensure Care Transition plan is provided to PCP; including identifying the patient’s most important health concerns and the patient’s immediate goals for recovery. 
  • Assist patient with transportation to post-discharge follow up appointments
  • Make follow-up Care Transition “Coaching” phone calls to the patient and/or family caregiver, once a week for 30 days or more frequent as needed.
  • Establish and leverage relationships with hospital discharge planners, inpatient social workers, primary care practices, and community and social service agencies to ensure the needs of members are met and policies of the plan are followed
  • Responsible for completing all documentation by the next business morning
  • Participate in weekly TOC team meetings and other UM and/or CMDM meetings as necessary
  • Participate in case conferences as needed
  • Meet case load assignments and productivity metrics as set my management
  • Tracks appropriate metrics and reports back to team on weekly basis about barriers, challenges, achievement, key learnings
  • Leads on-going self-evaluation and focused feedback activities
  • Provide training, development, and continuing education to staff as requested
  • Maintain professional and technical knowledge
  • Perform other duties as assigned




  • Licensed Clinical Social Worker or Master’s Degree in Social Work from an accredited graduate school of Social Work
  • Al least two years direct service experience with Medi-Cal population in an inpatient or outpatient setting
  • Have a cleared TB test prior to or within seven days of hire.
  • Current CPR and first aid card prior to or within six months of hire is preferred.
  • Transition of Care Certification preferred




  • Minimum two years of clinical experience in an acute care or care facility setting
  • Minimum two years working within the health care/managed care environment preferred
  • Minimum of two years of transition of care experience preferred




  • Knowledge of and experience with the underserved population
  • Knowledge of and experience with community and other resources
  • Experience in a medical/public health setting preferred
  • Ability to prioritize case load
  • Ability to make thoughtful decisions and exercise sound judgment.
  • Ability to analyze and synthesize UM and care coordination information.
  • Experience with planning, implementing, and evaluating clinical and disease prevention programs.
  • Background in population-based community health assessment and interventions.
  • Ability to work effectively in a multidisciplinary approach in management.
  • Ability to communicate effectively, both verbally and in writing.
  • Possess flexibility and creativity.
  • Familiarity with programmatic and clinical research strategies in managed care settings preferred.
  • Experience in use of various computer system software as well as Windows, Microsoft Word, Excel, Outlook, and PowerPoint.
  • Ability to communicate in Spanish or Chinese preferred

Pay Range:

$58,760 - $88,150/annually


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