Transitions of Care Manager, Jail

Who we are

About the Role:

The Licensed Carceral Transitions of Care Manager (CT CM) is responsible for pre-release planning and short-term case management of members releasing from city and county jails, Department of Corrections, JR, and JD facilities, ensuring they are safely and effectively transitioned back into community settings. Provides short-term care management services for members with highly complex behavioral health, medical, and social conditions. Working within a multi-functional team, the CT CM connects with members, correctional facility staff, providers, caregivers, contracted vendors, community resources, and health plan partners to assess the member's reentry into the community, identify care needs, and ensure access to appropriate services to achieve positive health outcomes.

This position is temporary, scheduled to end in June of 2028.

To be successful in this role, you:

• Have a current, unrestricted license in the State of Washington as a Registered Nurse (RN), or Social Worker (LICSW or LASW), required.
• Have a background in behavioral health, experience working with diverse populations, or collaborating with justice involved individuals.
• Have experience with community resources such as Regional Centers, Medicaid mental health and substance abuse services.
• You currently possess or have the ability to obtain a National Provider Identifier (NPI) number and register with Washington State Medicaid ProviderOne.
• Possess a valid WA driver's license and have access to a reliable automobile.

Essential functions and Roles and Responsibilities:

• Identifies, locates, and determines custody status of Apple Health Fee-for-Service justice involved members. Advocates on behalf of and facilitates coordination of resources required to help justice involved members reach optimum functional levels upon reentry to the community during transition and provides short-term case management. 

• Works with the city and county jails, Department of Corrections facilities, and Juvenile Rehabilitation facilities and a multi-functional team to connect with providers, caregivers, contracted vendors, community resources, and health plan partners to assess the member's health status, identify care needs and ensure access to appropriate services to achieve positive health outcomes upon reentry to the community. 

• Performs the primary functions of assessment, planning, facilitation, and advocacy through collaboration with the member, city and county jails, Department of Corrections, and Juvenile Rehabilitation facilities and other health care resources involved in the member's transition post-release. 

• Meets with the justice involved members via phone or video conferencing at city and county jails, Department of Corrections, and Juvenile Rehabilitation facilities. 

• Documents all case activity using the CHPW care management system and follows documentation standards and protocols. 

• Participates in telephonic/and or video discharge planning meetings and interdisciplinary care conferences, when appropriate and necessary. 

• Schedules medical, mental health, dental, and/or vision appointments in accordance with the member’s release date. Schedule transportation to appointments if required. 

• Conducts comprehensive social determinants of health (SDoH) assessments and coordinates care plan needs to address identified gaps. 

• Communicates with the members pertinent providers to discuss discharge plans and provide updates on status. 

• This position requires traveling on behalf of the Company and working in the field at least 10% of the time. It is essential that a current driver’s license, proof of insurance and an acceptable driving record are maintained. 

• Other duties as assigned. Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion.  

Knowledge, Skills, and Abilities: 

• Excellent clinical research and assessment skills.
• Ability to work independently.
• Highly skilled in project and work plan management.
• Knowledge of care management workflow systems.
• Well developed analytical skills and critical thinking skills.
• Excellent written and verbal communication skills; able to communicate with and collaborate effectively with internal departments, physicians and allied health care providers
• Proficiency in Microsoft Office applications.
• Ability to travel as necessary.
• Ability to obtain a National Provider Identifier (NPI) number.

As part of our hiring process, the following criteria must be met:

• Complete and successfully pass a criminal background check.

Criminal History: includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment. The applicant’s criminal history will be reviewed on a case-by-case basis considering the risk to the business, members, and/employees.

• Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.
• Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation

Compensation and Benefits:

The position is FLSA Non-Exempt and is eligible for overtime. Based on market data, this position grade is 46 (see full range below).

CHPW offers the following benefits for Full and Part-time employees and their dependents: 

•  Medical, Prescription, Dental, and Vision
•  Telehealth app
•  Flexible Spending Accounts, Health Savings Accounts
•  Basic Life AD&D, Short and Long-Term Disability
•  Voluntary Life, Critical Care, and Long-Term Care Insurance
•  401(k) Retirement and generous employer match
•  Employee Assistance Program and Mental Fitness app
•  Financial Coaching, Identity Theft Protection
•  Time off including PTO accrual starting at 17 days per year.
•  40 hours Community Service volunteer time
•  10 standard holidays, 2 floating holidays
•  Compassion time off, jury duty pay.

Sensory/Physical/Mental Requirements:

Sensory*:

• Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

Physical*:

• Extended periods of sitting, computer use, talking and possibly standing.
• Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion.
• Frequent torso/back static position; occasional stooping, bending, and twisting.
• Some kneeling, pushing, pulling, lifting, and carrying (not over 25 pounds), twisting, and reaching.

Mental:

• Must be able to manage conflict, communicate effectively and meet time-sensitive deadlines.

Work Environment:

Office environment Employees who frequently work in front of computer monitors are at risk for environmental exposure to low-grade radiation.