Transition Planner
Amae Health
We are growing our presence in Charlotte, NC and are hiring a Transition Planner to support our patients in their care journey. Reporting to the Chief Strategy Officer, and in collaboration with our Clinic Director, Psychiatrists, Primary Care Providers, Therapists, Dieticians and Clinic Care Coordinators, you will work closely with patients to address problems, answer questions, gather and provide information and advice; with the goal of connecting patients to resources and to the community. You will bridge the gaps in our patient’s care journeys, meeting patients where they are at - in the hospital, the community and at times in their homes to facilitate and connect them with the care they need.
- Represent Amae Health in the ER, inpatient, and outpatient hospital setting with our collaborating health systems, social workers, and providers to coordinate patient transitions to Amae, ensuring continuity of care as patients begin their care journey with Amae Health
- Provide initial case consultations to patients and families through video, phone, or in-person visits, often in high-pressure, time-sensitive environments. Collaborate with a multidisciplinary team and establish and maintain trust and rapport with patients, families and teammates
- Actively manage and grow enrollment in targeted regions through systematic outreach, ensuring a steady pipeline of patient referrals.
- Evaluate and track the effectiveness of outreach initiatives, pivoting as necessary to meet growth goals.
- Identify leads for service expansion and develop strategies for assigned areas.
- Establish and maintain relationships with community-based resources (e.g., NAMI), and advocate for Amae Health’s services.
A true patient advocate, you excel in using your knowledge of Charlotte's health systems and services to connect patients to the most appropriate resources in order to support their care journeys. Strong communication skills and an inherent ability to build trust are your hallmarks, and you are passionate about initiating, establishing and maintaining relationships with patients and families that are founded on trust and rapport. You are adaptable, flexible and organized, people centered, and excited about the opportunity to be part of a team that is changing how SMI care is delivered in our community.
- 1+ years of patient facing experience as a social worker, discharge planner or transition planner in a hospital setting
- A BSW OR MSW degree OR an unrestricted active license in California as a Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), or Licensed Professional Counselor (LPC) is required
- Knowledge of and familiarity with the mental health and social service systems in the Charlotte area and an understanding of patient rights and a holistic perspective of “health”
- Demonstrated skill and adaptability in working with people from diverse backgrounds in a variety of settings
- Current driver’s license, proof of acceptable automobile insurance coverage, and reliable transportation
- Ability to travel 90% of the time to surrounding hospitals and providers
- Comfort working one-on-one or in group settings, with experience facilitating workshops, events or activities
- Excellent communication skills and a strong desire to collaborate with others in a team based environment and community settings
- Organized with strong attention to detail and the ability to navigate and learn new technologies and platforms, familiarity with EHR, CRM systems, Slack and Google Suite desire
- Health Insurance: Comprehensive medical, dental & vision plans
- Employee Assistance Program
- 401(k)
- FSA & HSA savings programs
- Short & long-term disability
- Pre-tax commuter assistance program
- Paid Time Off
- Parental Leave - 12 weeks for birth and non birth parent
- 11 company holidays