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.  

Key Responsibilities:

1. 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 (e.g., Medically Tailored Meals, Housing Transition and Navigation, Asthma Remediation, etc.
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 the network by making appropriate referrals to Behavioral Health, Enhanced Care Management, and Complex Care Management.
4. 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.  
5. Participate in Integrated Transitional of Care Team meetings, Interdisciplinary Care Conferences, and any other meetings as required.  
6. Model continuous quality improvement philosophy and engage in quality improvement initiatives and projects.
7. Model supportive and collaborative relationships with Members, co-workers, facility partners, and community providers.
8. Engage in all Team Member training and comply with all policies.

• Minimum of three (3) 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

Key Qualifications 

• 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