Transitions of Care Manager, Jail

About the role

The Licensed Carceral Transitions of Care Manager (CT CM) is responsible for pre-release planning and short-term case management of members releasing from city and county jails, Department of Corrections, JR, and JD facilities, ensuring they are safely and effectively transitioned back into community settings. Provides short-term care management services for members with highly complex behavioral health, medical, and social conditions. Working within a multi-functional team, the CT CM connects with members, correctional facility staff, providers, caregivers, contracted vendors, community resources, and health plan partners to assess the member's reentry into the community, identify care needs, and ensure access to appropriate services to achieve positive health outcomes.

Responsibilities

• Identifies, locates, and determines custody status of Apple Health Fee-for-Service justice involved members.
• Advocates on behalf of and facilitates coordination of resources required to help justice involved members reach optimum functional levels upon reentry to the community during transition and provides short-term case management.
• Works with the city and county jails, Department of Corrections facilities, and Juvenile Rehabilitation facilities and a multi-functional team to connect with providers, caregivers, contracted vendors, community resources, and health plan partners to assess the member's health status, identify care needs and ensure access to appropriate services to achieve positive health outcomes upon reentry to the community.
• Performs the primary functions of assessment, planning, facilitation, and advocacy through collaboration with the member, city and county jails, Department of Corrections, and Juvenile Rehabilitation facilities and other health care resources involved in the member's transition post-release.
• Schedules medical, mental health, dental, and/or vision appointments in accordance with the member’s release date. Schedule transportation to appointments if required.
• Conducts comprehensive social determinants of health (SDoH) assessments and coordinates care plan needs to address identified gaps.
• Communicates with the members pertinent providers to discuss discharge plans and provide updates on status.

Requirements

• Current, unrestricted license in the State of Washington as a Registered Nurse (RN), or Social Worker (LICSW or LASW), required.
• Background in behavioral health, experience working with diverse populations, or collaborating with justice involved individuals.
• Experience with community resources such as Regional Centers, Medicaid mental health and substance abuse services.
• Ability to obtain a National Provider Identifier (NPI) number and register with Washington State Medicaid ProviderOne.
• Valid WA driver's license and access to a reliable automobile.

Skills

• Excellent clinical research and assessment skills.
• Ability to work independently.
• Highly skilled in project and work plan management.
• Knowledge of care management workflow systems.
• Well developed analytical skills and critical thinking skills.
• Excellent written and verbal communication skills; able to communicate with and collaborate effectively with internal departments, physicians and allied health care providers.
• Proficiency in Microsoft Office applications.
• Ability to travel as necessary.
• Ability to obtain a National Provider Identifier (NPI) number.

Benefits

• Medical, Prescription, Dental, and Vision Telehealth app
• Flexible Spending Accounts, Health Savings Accounts
• Basic Life AD&D, Short and Long-Term Disability
• Voluntary Life, Critical Care, and Long-Term Care Insurance
• 401(k) Retirement and generous employer match
• Employee Assistance Program and Mental Fitness app
• Financial Coaching, Identity Theft Protection
• Time off including PTO accrual starting at 17 days per year.
• 40 hours Community Service volunteer time
• 10 standard holidays, 2 floating holidays
• Compassion time off, jury duty pay.