Social Work Care Manager, Care Transitions

Avail HealthRockville, Maryland

$70,000 - $87,500 / year

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Overview

Schedule

Full-time

Education

Social Work (LSW, LMSW, LICSW)

Career level

Senior-level

Remote

Hybrid remote

Compensation

$70,000-$87,500/year

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Job Description

Role Overview

Avail Health is launching a hospital-based Care Transitions Program supporting Medicare patients with complex medical, behavioral health, and social needs following discharge. The Social Work (SW) Care Manager leads the behavioral health track of that program — serving as the primary clinical point of contact for patients whose post-discharge complexity is driven primarily by serious mental illness, psychosocial barriers, or SDOH needs.Day-to-day you’ll conduct post-discharge outreach, assess SDOH and behavioral health status, develop and monitor care plans, coordinate community resources, and prepare pre-visit clinical documentation for the NP’s TCM encounter. You’ll work closely with the RN Care Manager, who leads the medical track panel, collaborating cross-functionally for patients where medical and behavioral health complexity overlap. Most of your work is virtual, with in-person visits when patients require a licensed assessment that can’t be completed via telehealth.This is a founding team role. You’ll help operationalize workflows, shape clinical protocols, and build a model designed to scale.

What You'll Own

Post-discharge outreach and ongoing clinical contact for assigned behavioral health track patients throughout the 30-day TCM episode

SDOH and behavioral health assessment, individualized care plan development, and community resource coordination

Pre-visit chart preparation and clinical synthesis for the NP’s TCM encounter

What You'll Do

Conduct post-discharge outreach within CMS TCM timelines; perform tuck-in calls for high-risk patients to validate discharge plan adherence and identify early barriers

Assess SDOH status (housing, food security, medication access, transportation, safety), behavioral health needs, symptom burden, and fall risk across the TCM episode

Develop and update individualized care plans addressing identified barriers; coordinate referrals, home services, social services, housing programs, and community resources

Perform comprehensive pre-visit chart prep: review discharge summaries, HIE data, psychiatric records, psychosocial assessments, and prior treatment history to support the NP’s TCM visit

Conduct in-person visits when patients require licensed assessment that cannot be completed virtually

Collaborate daily with the RN Care Manager, NP, and Care Coordinator in team huddles; present clinical priorities using SBAR and contribute to risk stratification

Consult with the RN Care Manager on medical questions for BH-panel patients; provide social needs and behavioral health input to the RN for medical-panel patients

Maintain timely, accurate documentation in compliance with TCM billing requirements and CMS guidelines

What Success Looks Like

Post-discharge outreach completed within CMS TCM timelines for 100% of assigned behavioral health track patients

SDOH and behavioral health barriers identified and care plans documented prior to the NP’s TCM visit

Community resources, referrals, and follow-up services coordinated without gaps for assigned patients

30-day readmission rate for the assigned BH-track panel at or below program benchmarks

Pre-visit clinical summaries complete and available to the NP prior to every scheduled TCM encounter

What You Bring

Required:

BSW from an accredited program; MSW strongly preferred

Active, unrestricted Maryland LCSW-C license in good standing

3+ years of post-licensure clinical social work experience with serious mental illness, complex behavioral health conditions, or high-risk adult populations in hospital, discharge planning, care transitions, or community-based settings

Experience in mobile or community-based care delivery with working knowledge of SDOH screening and community resource navigation

Ability to access, interpret, and synthesize multi-source clinical and social data including HIE records, psychiatric histories, and psychosocial assessments

Valid driver’s license, reliable transportation, and active automobile insurance

Reliable high-speed internet and a dedicated, HIPAA-compliant home workspace

Preferred:Experience with Medicare-aged populations with serious mental illness, dual diagnosis, or medically complex behavioral health needs

Background in psychiatric hospital discharge planning, ACT, community mental health case management, TCM, or longitudinal complex care management

Familiarity with HIE platforms, telehealth tools, or supporting patients with limited technology access

Experience in an early-stage or startup-style healthcare environment with evolving workflows

Schedule and Work Style

Work Type: Hybrid — primarily remote with in-person visits when clinically indicatedSchedule: Monday–Friday, 8:00 AM – 5:00 PM ET; occasional on-call as program scalesTravel: Field visits across Montgomery County, MD; must reside within commuting distance of RockvilleAutonomy: High clinical independence with daily interdisciplinary team touchpoints

Compensation and Perks

Salary Range: $70,000 – $87,500 annually, commensurate with experienceKey Benefits:Medical, dental, and vision insurance

HSA

| 401(k) with employer match

15 days PTO

| 8 + 1 floating holidays

Professional liability and malpractice insurance provided

All devices for clinical and technology-related activities provided

About Avail Health

Avail Health is a Nurse Practitioner–founded organization delivering mobile and virtual care to Medicare-age patients. We combine technology, operational rigor, and clinical excellence to improve outcomes for complex populations. For more visit www.availhealthcare.co

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FAQs About Social Work Care Manager, Care Transitions Jobs at Avail Health

What is the work location for this position at Avail Health?

This job at Avail Health is located in Rockville, Maryland, according to the details provided by the employer. Some roles may also include multiple work locations depending on the requirement.

What pay range can candidates expect for this role at Avail Health?

Candidates can expect a pay range of $70,000 and $87,500 per year.

What employment applies to this position at Avail Health?

Avail Health lists this role as a Full-time position.

What experience level is required for this role at Avail Health?

Avail Health is looking for a candidate with "Senior-level" experience level.

What education level is required for this job?

The education requirement for this position is Social Work (LSW, LMSW, LICSW). Candidates with relevant qualifications or equivalent experience may also be considered.

What benefits are offered by Avail Health for this role?

Avail Health offers following benefits: Health Insurance, Dental Insurance, Vision Insurance, Paid Holidays, Paid Vacation, and 401k Matching/Retirement Savings for this position. Actual benefits may vary depending on the employer's policies and employment terms.

What is the process to apply for this position at Avail Health?

You can apply for this role at Avail Health either through Sonara's automated application system, which helps you submit applications 10X faster with minimal effort, or by applying manually using the direct link on the job page.