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As the nations leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Company: Oak Street Health

Title: Lead, Transitional Care Manager, SW

Location: TBD

Oak Street Health is a rapidly growing, innovative company of community-based healthcare centers that provides higher quality health and wellness care that improves outcomes, manages medical costs, and provides an unmatched experience for adults on Medicare in medically underserved communities. By providing holistic, comprehensive and integrated care right in our patients communities, we can keep our patients healthy and then reinvest cost savings in further care for those same communities and others. Since 2013, Oak Street Health has brought its singular approach to tens of thousands of people in Illinois, Indiana, Michigan, Ohio, Tennessee, North Carolina and Texas. At 56 locations, and with an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody Oak Street values and are passionate about the mission to rebuild healthcare as it should be.

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Role description:

Oak Street Health takes a team-based approach to providing outstanding patient care. The Transitional Care Manager (TCM) Lead is an integral part of the team. The OSH Transitions of Care program focuses on providing a multi-disciplinary connection between OSH Care Navigation, Utilization Management, facility, local care teams and patient/family. The TCM Lead is responsible for providing day-to-day oversight and support to TCMs and executing the Transitions of Care program goals, which include ensuring high-quality, patient-centered care; preventing avoidable readmissions; and managing efficient resource utilization and improving patient and provider satisfaction.

Responsibilities:

• Supervise the Transitional Care Managers in assigned markets, including clinical oversight of the following daily operations and metrics:
  
  • Transitions management: evaluating patient status through clinical assessments and medical record review; inpatient and post-acute discharge planning; reconciling medication lists on behalf of the primary care provider (PCP); and scheduling post-discharge visits with the PCP
  • Coordination with utilization management: partnering with UM to review medical and payer records to ensure appropriate length of stay and identify and address any barriers to discharge.
  • Collaboration and communication with internal stakeholders: coordinating with internal stakeholders (e.g. care team, social work, behavioral health, utilization management, Hard-to-Reach, Central Telehealth, etc.) to promote patient outreach and engagement and identify and address patient needs
  • Collaboration and communication with external stakeholders: Engaging directly with inpatient physicians, case managers, medical directors, social workers, and hospitalists/SNFists (where applicable) to facilitate safe and timely discharge and appropriate follow-up care; and identifying partnership development opportunities and systems improvements.
  • Documentation, tracking, reporting and training: documenting and monitoring transitions activities and effectiveness; participating in regular trainings; evaluating quality and impact of transitions activities
• Balance staff caseloads and provide coverage and support as needed.
• Maintain up to 50% of a panel, depending on the clinical scope of the transitions program in specific regions
• Monitor team and individual performance and coach team members to improve performance when appropriate.
• Provide direct or supporting efforts in the hiring and training of Transitional Care Managers in assigned regions.
• Assist with the implementation of transitional care activities and programming
• Execute effective collaboration between multi-disciplinary teams, including but not limited to: OSH Care Navigation, Utilization Management, facilities, local care teams and patient/family.

• Adhere to CMS, state specific and NCQA compliance criteria as related to Transitions of Care.
• Monitor OSH data related to patient cost, admissions, post-discharge appointment completion and health outcomes to help guide and direct Transitions of Care program initiatives and goals.

Ideal candidates have:

• An active LCSW license within the state of practice in good standing
• Cross-state licensure preferred, or willingness to obtain cross-state licensure
• Certified Case Manager (CCM) required, or willingness to obtain within 12 months of hire
• Minimum 2 years of direct supervisory experience
• 2+ years of experience in transitional care nursing, discharge planning or home health
• Experience in utilization management

• Knowledge of Medicare/Medicaid and NCQA regulatory transitions of care criteria
• Strong clinical and assessment skills
• Outstanding verbal and written communication skills
• Ability to work independently and maintain flexibility in a fast-paced, start-up environment
• Ability to analyze data and use it to improve care delivery
• Self-starter with a high level of accountability and responsibility for the outcome of care
• Highly organized and able to manage multiple priorities appropriately
• Independent problem-solving skills
• Able to work collaboratively and build enduring relationships with providers, patients and the multidisciplinary team.
• A flexible, positive attitude
• Valid drivers license and ability to travel daily
• Ability to supervise home visits (virtually or in person) as needed
• Working knowledge of Microsoft Office Product Suite
• US work authorization
• Someone who embodies being "Oaky"

What does being "Oaky" look like?

• Radiating positive energy
• Assuming good intentions
• Creating an unmatched patient experience
• Driving clinical excellence
• Taking ownership and driving for results
• Being relentlessly determined

Why Oak Street?

Oak Street Health offers our coworkers the opportunity to be at the forefront of a revolution in healthcare, as well as:

• Collaborative and energetic culture
• High levels of responsibility and rapid advancement
• Headquarters (the "Treehouse") located in the heart of Downtown, close to many public transit options and great restaurants
• Competitive benefits; including paid vacation/sick time, generous 401K match with immediate vesting, as well as health benefits

Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply to oakstreethealth.com/careers.

Anticipated Weekly Hours
40

Time Type
Full time

Pay Range

The typical pay range for this role is:

$88,374.00 - $190,344.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

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