Transitional Care Manager Social Worker (License Required))

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...