Social Work Care Transition Specialist

SilverStay • Baltimore, MD

24d • Onsite

About The Position

This is an embedded Care Transition Specialist role, physically based at the University of Maryland Medical System in Baltimore. You will serve as SilverStay's on-the-ground presence — managing contract cases from referral through discharge, conducting bedside visits, coordinating ALF tours, and ensuring every transition closes cleanly. You'll work directly within hospital systems (including EPIC), giving you real-time access to patient notes and the ability to act fast when cases evolve. This role was designed for someone who has been here before — who knows how hospital discharge planning works, can manage 10–15 active contract cases simultaneously, and thrives in a high-pressure, fast-moving environment. You will not be starting from scratch; you'll be stepping into an active book of business with a team behind you.

Requirements

• Active Maryland Social Work license (LCSW or LCSW-C) — strongly preferred
• 3+ years of experience in hospital discharge planning, care transitions, or a closely related clinical-social work role
• Hands-on familiarity with hospital EHR and care coordination systems (comfort learning new systems is a must)
• Demonstrated ability to manage complex, fast-moving caseloads with multiple stakeholders — families, hospitals, ALFs, payers
• A track record of placing 2+ clients per week in appropriate care settings
• Strong emotional intelligence — able to navigate high-stress family dynamics with calm, empathy, and decisiveness
• Local to Baltimore with reliable transportation, a valid MD driver's license, and genuine availability for in-person work including occasional weekends
• Self-directed, responsive, and organized — you own your caseload and don't need to be managed step-by-step

Nice To Haves

• EPIC experience is a plus

Responsibilities

• Own Contract Cases End-to-End: Manage the full contract case lifecycle — referral intake, options sourcing, family outreach, bedside visits, ALF coordination, and discharge follow-through.
• Stay Ahead in EPIC: Access and monitor EPIC (and other hospital EHR systems) to stay current on patient status, updated notes, and clinical changes — proactively, not reactively.
• Manage an Active Caseload: Handle 10–15 active referrals at any given time, maintaining thorough and timely documentation in SilverStay's CRM.
• Be Present Where It Counts: Conduct in-person bedside visits and attend ALF tours when needed; weekend availability is a real expectation for this role and will be set as such upfront.
• Serve as SilverStay's On-Site Liaison: Build trusted working relationships with case managers, social workers, and discharge planning teams at University of Maryland.
• Support the Broader Team: Handle the volume of requests that come directly from the hospital — inquiries, logistical coordination, referral follow-up — so the broader team can stay focused on tours and sourcing.
• Collaborate & Follow Through: Work closely with the SilverStay Baltimore team, share case updates, escalate complex situations, and provide ongoing follow-up with clients and families for a minimum of 30 days post-transition.

Benefits

• Health, dental, and vision benefits
• Mileage reimbursement at the IRS standard rate for all approved travel
• Recognition & Growth: As SilverStay expands, your dedication will open doors for advancement.
• High-Trust Culture: Low bureaucracy, direct feedback, and a team that respects your expertise and autonomy.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 1-10 employees