Lead the behavioral health track of a hospital-based Care Transitions Program by conducting post-discharge outreach and assessing social determinants of health. Coordinate community resources and prepare clinical documentation to support Nurse Practitioners in managing complex Medicare patients.
Requirements summary
Requires a BSW (MSW preferred) and an active Maryland LCSW-C license with at least 3 years of clinical experience with high-risk adult populations. Must possess a valid driver's license and the ability to synthesize multi-source clinical data.
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
Benefits
Dental Insurance
Vision Insurance
Medical Insurance
HSA
401(k) With Employer Match
15 Days PTO
8 Floating Holidays
Professional Liability And Malpractice Insurance
Clinical And Technology Devices Provided
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 indicated
Schedule: Monday–Friday, 8:00 AM – 5:00 PM ET; occasional on-call as program scales
Travel: Field visits across Montgomery County, MD; must reside within commuting distance of
Rockville
Autonomy: High clinical independence with daily interdisciplinary team touchpoints Compensation and Perks
Salary Range
$70,000 – $87,500 annually, commensurate with experience Key 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
