Social Work Care Manager, Care Transitions

Job Description

Job Description

Role Overview Avail Health is launching a hospital-based Care Transitions Program supporting Medicare patients with complex medical, behavioral health, and social needs following discharge. The Social Work (SW) Care Manager leads the behavioral health track of that program — serving as the primary clinical point of contact for patients whose post-discharge complexity is driven primarily by serious mental illness, psychosocial barriers, or SDOH needs.
Day-to-day you’ll conduct post-discharge outreach, assess SDOH and behavioral health status, develop and monitor care plans, coordinate community resources, and prepare pre-visit clinical documentation for the NP’s TCM encounter. You’ll work closely with the RN Care Manager, who leads the medical track panel, collaborating cross-functionally for patients where medical and behavioral health complexity overlap. Most of your work is virtual, with in-person visits when patients require a licensed assessment that can’t be completed via telehealth.
This is a founding team role. You’ll help operationalize workflows, shape clinical protocols, and build a model designed to scale. What You'll Own •   Post-discharge outreach and ongoing clinical contact for assigned behavioral health track patients throughout the 30-day TCM episode
•   SDOH and behavioral health assessment, individualized care plan development, and community resource coordination
•   Pre-visit chart preparation and clinical synthesis for the NP’s TCM encounterWhat You'll Do•   Conduct post-discharge outreach within CMS TCM timelines; perform tuck-in calls for high-risk patients to validate discharge plan adherence and identify early barriers
•   Assess SDOH status (housing, food security, medication access, transportation, safety), behavioral health needs, symptom burden, and fall risk across the TCM episode
•   Develop and update individualized care plans addressing identified barriers; coordinate referrals, home services, social services, housing programs, and community resources
•   Perform comprehensive pre-visit chart prep: review discharge summaries, HIE data, psychiatric records, psychosocial assessments, and prior treatment history to support the NP’s TCM visit
•   Conduct in-person visits when patients require licensed assessment that cannot be completed virtually
•   Collaborate daily with the RN Care Manager, NP, and Care Coordinator in team huddles; present clinical priorities using SBAR and contribute to risk stratification
•   Consult with the RN Care Manager on medical questions for BH-panel patients; provide social needs and behavioral health input to the RN for medical-panel patients
•   Maintain timely, accurate documentation in compliance with TCM billing requirements and CMS guidelines What Success Looks Like •   Post-discharge outreach completed within CMS TCM timelines for 100% of assigned behavioral health track patients
•   SDOH and behavioral health barriers identified and care plans documented prior to the NP’s TCM visit
•   Community resources, referrals, and follow-up services coordinated without gaps for assigned patients
•   30-day readmission rate for the assigned BH-track panel at or below program benchmarks
•   Pre-visit clinical summaries complete and available to the NP prior to every scheduled TCM encounter What You Bring Required:
•   BSW from an accredited program; MSW strongly preferred
•   Active, unrestricted Maryland LCSW-C license in good standing
•   3+ years of post-licensure clinical social work experience with serious mental illness, complex behavioral health conditions, or high-risk adult populations in hospital, discharge planning, care transitions, or community-based settings
•   Experience in mobile or community-based care delivery with working knowledge of SDOH screening and community resource navigation
•   Ability to access, interpret, and synthesize multi-source clinical and social data including HIE records, psychiatric histories, and psychosocial assessments
•   Valid driver’s license, reliable transportation, and active automobile insurance
•   Reliable high-speed internet and a dedicated, HIPAA-compliant home workspace

Preferred:
•   Experience with Medicare-aged populations with serious mental illness, dual diagnosis, or medically complex behavioral health needs
•   Background in psychiatric hospital discharge planning, ACT, community mental health case management, TCM, or longitudinal complex care management
•   Familiarity with HIE platforms, telehealth tools, or supporting patients with limited technology access
•   Experience in an early-stage or startup-style healthcare environment with evolving workflows Schedule and Work Style Work Type: Hybrid — primarily remote with in-person visits when clinically indicated
Schedule: Monday–Friday, 8:00 AM – 5:00 PM ET; occasional on-call as program scales
Travel: Field visits across Montgomery County, MD; must reside within commuting distance of Rockville
Autonomy: High clinical independence with daily interdisciplinary team touchpoints Compensation and Perks Salary Range: $70,000 – $87,500 annually, commensurate with experience
Key Benefits:
•   Medical, dental, and vision insurance
•   HSA  |  401(k) with employer match
•   15 days PTO  |  8 + 1 floating holidays
•   Professional liability and malpractice insurance provided
•   All devices for clinical and technology-related activities provided About Avail Health Avail Health is a Nurse Practitioner–founded organization delivering mobile and virtual care to Medicare-age patients. We combine technology, operational rigor, and clinical excellence to improve outcomes for complex populations. For more visit

 

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