CASE MANAGER (LCSW) TRANSITION OF CARE

UHS•Guaynabo, Puerto Rico

About The Position

The Transition of Care Coordinator oversees the daily operations of the Mental Health Transitions of Care Program and coordinates behavioral health services after discharge from inpatient settings. The role reviews discharge plans, monitors members at risk for readmission or disruption of care, ensures timely follow-up appointments, facilitates communication among healthcare providers and caregivers, supports medication reconciliation, and coordinates crisis interventions when clinically indicated. The coordinator promotes person-centered, trauma-informed, culturally responsive, and recovery-oriented care to support successful transitions and continuity of treatment. The position manages staff assignments, caseload distribution, scheduling, productivity expectations, and workforce performance. It develops and updates workflows and standard operating procedures, prepares program reports and presentations for organizational leadership, and supports program quality, regulatory compliance, and continuous improvement. The position also participates in interdisciplinary care teams and consults with clinical and non-clinical staff. Travel within Puerto Rico may be required.

Requirements

Master’s degree in social work, psychology, psychological counseling, mental health counseling, or psychiatric nursing.
Valid, current, active license in social work, psychiatric nursing, psychological counseling, psychology, or mental health counseling.
Valid professional association membership (colegiación) for social work and psychiatric nursing.
Two or more years of experience in the health field.
Knowledge of Microsoft Office.

Nice To Haves

Fully bilingual.

Responsibilities

Identify eligible individuals in the behavioral health inpatient census; review ongoing hospitalizations and discharges to facilitate safe transitions between care settings.
Coordinate with inpatient facility teams to track clinical status, discharge readiness, social determinants of health, and barriers affecting transitions and continuity of care.
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.
Document transition-of-care strategies, coordination, assessments, and meaningful interactions with patients and healthcare providers to support successful transitions and compliance.
Assess and monitor risks related to readmission, relapse, medication non-adherence, and deterioration in mental health during the transition period.
Provide transitional care planning and education on diagnoses, treatment, early warning signs, and crisis prevention; address social determinants of health and facilitate continuity supports in community settings.
Coordinate referrals to community-based resources and physical health services to address identified needs.
Communicate with health plans, primary care and behavioral health providers, community organizations, and internal departments to coordinate member-centered transitions.
Serve as liaison among the Contact Center, Community Outreach Mental Health Workers, and Transition of Care staff; collaborate to reduce members who cannot be contacted and refer cases to outreach workers and case managers as needed.
Review cases against clinical guidelines, organizational policies, contractual requirements, and accreditation standards; monitor performance indicators including post-discharge follow-up, readmission rates, and continuity of care.
Conduct case reviews and interdisciplinary meetings, identify care gaps, implement corrective actions and process improvements, audit documentation, ensure compliance with HIPAA and behavioral health confidentiality requirements, and participate in audits and corrective action planning.
Participate in interdisciplinary care team meetings and case discussions, applying integrated care models to monitor member outcomes and optimize service delivery.
Remain available to 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 assigned duties that support program goals and community mental health service coordination.
Travel within Puerto Rico as necessary to fulfill job responsibilities.