Social Work Transition Manager

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 Social Work license in Maryland
2+ 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 (EPIC experience is a plus; 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

Responsibilities

Manage the full contract case lifecycle — referral intake, options sourcing, family outreach, bedside visits, ALF coordination, and discharge follow-through.
Access and monitor EPIC (and other hospital EHR systems) to stay current on patient status, updated notes, and clinical changes — proactively, not reactively.
Handle 10–15 active referrals at any given time, maintaining thorough and timely documentation in SilverStay's CRM.
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.
Build trusted working relationships with case managers, social workers, and discharge planning teams at University of Maryland.
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.
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.