Integrated Transitional Care Manager, LCSW

(ITC CM LCSW)

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. 
As a licensed behavioral health clinician, the individual in this position is to utilize their clinical expertise to support and engage Members to promote positive health behaviors, assist with coordination of care, provided resource linkages, and collaborate with other Team Members of this integrated care team, as well as facility partners, to ensure a seamless transitions of care experience.  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.

Key Responsibilities:

1. Assist Members with care coordination needs, including, but not limited to the following:
    a. Conduct comprehensive, holistic assessment both telephonically as well as in person (facility or home visits).
    b. Assimilate assessment information to assist, in collaboration with the ITC Team and the facility, in developing a discharge plan.  
    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 to support Members’ comprehensive care needs.
2. Model the highest ethical behavior in care for Members, as well as in relationships with co-workers, Leaders, internal, and external partners.  
3. Advocate for Members to receive the highest quality care, in a timely manner, within network by referring to appropriate internal partners such as behavioral health, Enhanced Care Management, and complex care management.
4. Provide transitional care services to Members transitioning from one care setting to the next such as assisting the Member with PCP appointments, transportations, and coordination of DME and home health.
5. Support Member through all care transitions by making outreach to ensure all care needs are met before closing the Member out to transitions of care. providing care coordination, linkage to resources, and facilitating Member self-efficacy and self-management.  
6. Participate in Integrated Transitional Care Team meetings, Interdisciplinary Care Conferences, and any other meetings as required.  
7. Model continuous quality improvement philosophy and engage in quality improvement initiatives and projects.
8. Model supportive and collaborative relationships with Members, co-workers, facility partners, and community providers.
9. Engage in all Team Member training and comply with all policies.

• Minimum of three (3) years of experience performing Behavioral Health/Medical Social Work services


• Experience in motivational interviewing and/or other evidenced-based communication strategies


• Master’s degree in Social Work from an accredited institution required


• Possession of an active, unrestricted, and unencumbered Clinical Social Worker (LCSW) license or Marriage and Family Therapist (LMFT) license issued by the California Board of Behavioral Sciences required

Key Qualifications 

• Bilingual (English/Spanish) preferred.


• Highly skilled in interpersonal communication, including conflict resolution.


• Effective written and oral communication skills, as well as reasoning and problem-solving skills


• Skillful in informally and formally sharing expertise


• Must have the resiliency to tolerate and adapt to a moderate level of change and development around new models of care and care management practices


• Proficient in the use of computer software including, but not limited to, Microsoft Word, Excel, PowerPoint


• Demonstrated proficiency with all electronic medical management systems (e.g., Cisco, MHK/Care Prominence, MediTrac, SuperSearch and Web Portal) is preferred