Transition Specialist

SilverStay • Baltimore, MD

2d • $70,000 - $85,000 • Onsite

About The Position

SilverStay is on a mission to be the leading healthcare services company nationwide for complex discharges by 2030. We provide solutions for medically and financially complex clients who are failing at home or transitioning out of the healthcare system. Our guideposts — Empathy, Creativity, Collaboration, and Ethical Conduct — mean we’re not just providing solutions, we’re changing healthcare.
This is an embedded 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 (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: you can navigate high-stress family dynamics with calm, empathy, and decisiveness
• Local to Baltimore — reliable transportation, 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

• Own 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
• Manage 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
• Serve as SilverStay’s on-site liaison at University of Maryland, building trusted working relationships with case managers, social workers, and discharge planning teams
• 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
• Be present and responsive during high-volume discharge periods; this is an embedded role, not a remote-first one
• Collaborate closely with the SilverStay Baltimore team, sharing case updates, escalating complex situations, and contributing to team case reviews
• Work with the Client Champion team on private pay and non-contract cases as bandwidth allows
• Provide ongoing follow-up with clients and families for a minimum of 30 days post-transition to confirm placement success and close the case properly

Benefits

• Health, dental, and vision benefits
• Mileage reimbursement at the IRS standard rate for all approved travel
• A high-trust, low-bureaucracy team environment where your work has direct, measurable impact

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 1-10 employees