CASE MANAGER (LCSW) TRANSITION OF CARE

Position Summary

The Transition of Care Coordinator oversees the daily operations of the Mental Health Transitions of Care Program and ensures the effective coordination of behavioral health services following discharge from inpatient settings. This includes reviewing discharge plans, monitoring members at risk for readmission or disruption of care, ensuring timely follow-up appointments, facilitating communication among healthcare providers and caregivers, supporting medication reconciliation, and coordinating crisis interventions when clinically indicated. The Transition of Care Coordinator also promotes person-centered, trauma-informed, culturally responsive, and recovery-oriented care to support successful transitions and continuity of treatment.

Job Duties/Responsibilities

• Identify individuals who meet the criteria for the Transition of Care program in the behavioral health inpatient census, review ongoing hospitalizations, and discharges to facilitate patient's safe transition between care settings.
• Coordinate with inpatient facility teams to track clinical status, readiness for discharge, social determinants of health and address barriers that may impact successful transitions and care continuum.
• Manage staff assignments, caseload distribution, scheduling, productivity expectations, and workforce performance.
• Develop and update workflows and standard operating procedures; prepare reports and presentations on program outcomes and trends for organizational leadership.
• Assure documentation of all Transition of Care strategies, internal and external coordination, assessments and meaningful interactions with patients and their healthcare providers to achieve a successful transition and compliance with quality measures, accreditations and regulatory requirements.
• Assess and monitor risks related to readmission, relapses, medication non-adherence, and deterioration in mental health status during the transition period.
• Provide transitional care planning, education on diagnoses and treatment, identification of early warning signs, crisis prevention strategies, social determinants of health and facilitation of continuity support within the community setting.
• Assure referrals and coordination to community-based resources and physical health services to address identified needs and support continuity of care.
• Communicate timely with health plan, primary care providers and behavioral health providers, community organizations and internal departments, including Utilization Review, Quality, Pharmacy, and Behavioral Contact Access Center, to ensure coordinated, member-centered transitions.
• Serve as the liaison between Contact Center, Community Outreach Mental Health Workers and Transition of Care staff working collaboratively to reduce unable to contact members.
• Provide referrals of cases to Outreach Community Mental Health Workers and Case Managers, as necessary.
• Maintain program quality and regulatory compliance by reviewing cases against clinical guidelines, organizational policies, contractual requirements, and accreditation standards.
• Monitor key performance indicators such as post-discharge follow-up, readmission rates, and continuity of care; conduct case reviews and interdisciplinary meetings; identify gaps in care; implement corrective actions and process improvement initiatives; audit documentation for quality and compliance; ensure adherence to HIPAA and behavioral health confidentiality requirements; and participate in internal and external audits and corrective action planning.
• Actively participate in interdisciplinary care team (ICT) meetings and case discussions, applying integrated care models to monitor member outcomes and optimize service delivery.
• Maintain timely availability to clinical and non-clinical staff for consultation, including same day availability for urgent consultations and availability within two business days for routine matters.
• Participate in team and interdepartmental meetings as required.
• Perform other duties assigned by supervisors that contribute to program goals and support community mental health service coordination.
• Be prepared to travel within Puerto Rico to fulfill job responsibilities as necessary.

Qualifications

• Master's in social work, Psychology, Psychological Counseling, Mental Health Counseling, or Psychiatric Nursing
• Valid and current active license for Social Work, Psychiatric Nursing, Psychological Counseling, Psychology, or Mental Health Counseling
• Professional associating membership (colegiación): valid membership for Social Work and Psychiatric Nursing
• Two or more years of experience in the health field
• Knowledge in Microsoft Office
• Preferred fully bilingual