Community Transition Social Worker

SilverStay • Baltimore, MD

10d • $55,000 - $65,000 • Hybrid

About The Position

At SilverStay, we’re on a mission to be the leading healthcare services company nationwide for complex discharges by 2030. We help hospitals, families, and post-acute providers work together to ensure even the most challenging patient discharges happen smoothly, quickly, and compassionately. We are seeking a proactive and highly organized Community Transition Social Worker to manage a caseload of approximately 50-60 patients currently residing in Assisted Living Facilities (ALFs) under hospital-funded contracts. The primary objective of this role is to successfully transition financial responsibility from the hospital to sustainable, safe and appropriate care settings. This is a hybrid role requiring onsite visits to facilities to liaise with community partners and facility administration.

Requirements

• Professional experience in Social Work, discharge planning, or Long-Term Care (LTC) settings.
• Active Social Work license required. Active Driver’s License also required.
• Strong knowledge of the aging population, geriatric resources, and complex payer systems (Medicaid Waivers).
• Knowledge of Google Sheets/Microsoft Excel & email communications.

Responsibilities

• Contract Conversion & Funding: Execute the strategic transition of patients from temporary hospital contracts to permanent payer sources, specifically navigating Medicaid waiver, LTC (Long Term Care) transitions and addressing citizenship/eligibility complexities.
• Caseload Management: Maintain meticulous oversight of a shared caseload of 50+, ensuring critical deadlines are met to prevent funding gaps or contract overstays.
• Community engagement: Traveling to meet patients, families, guardians and/or ALF providers to ensure engagement and collaboration for transition needs. 90% of travel within the Baltimore area, expanding to surrounding counties in Maryland.
• Reporting: Generate detailed Monthly Summaries regarding patient status, waiver application progress, and barriers to contract resolution.
• Liaison Work: Act as the primary bridge between the hospital and ALF providers to ensure continuity of care while finalizing permanent placement arrangements.

Benefits

• Comprehensive medical, dental, and vision coverage - including spouse and family.
• 401(k) with employer contribution.
• Generous PTO plus holidays.
• Flexible schedule with autonomy to structure your time around outcomes, not shifts.
• Ongoing training, mentorship, and opportunities to grow into leadership as SilverStay expands.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed