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Care Transitions Specialist

Date: Aug 13, 2019

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 2955 




Under the direction of the Long-Term Care (LTC) Custodial Manager and Supervisor, the Care Transitions Specialist is responsible for assisting the Care Transitions Social Worker in facilitating the identification and safe transition of IEHP Members in custodial level of care who may be appropriate for transition back into the community. 




  1. Assist the Care Transitions Social Worker in the identification and coordination of care of Members in custodial care who may be appropriate to transition back into the community.  
  2. Perform facility site visits to communicate with Member and/or family members health plan benefits, available community resources, and Member’s goals for transition, if appropriate. 
  3. Work closely with the IEHP LTC Custodial Placements and Transitions Team as well as the Care Transitions Social Worker to develop a safe discharge plan for Member’s transition back into the community. 
  4. Work with Members and family members to identify needs and appropriate resources, help navigate the system and provide guidance for a successful transition to the community.
  5. Communicate with Providers regarding Member follow-up visits, community resources, and other matters pertinent to the Member’s transition back into the community.
  6. Collaborate with other IEHP departments such as Community Health, Care Management, Behavioral Health, and Independent Living and Diversity Services, to assist in the safe transition of Members from custodial level of care back into the community.
  7. Maintain appropriate documentation, as per UM LTC Custodial Team guidelines, in the medical management system.
  8. Participate in multidisciplinary team meetings, e.g., interdisciplinary case conferences, Housing Team Meetings, Educational Rounds, and other meetings as required.
  9. Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP’s policies and procedures relating to HIPAA compliance.
  10. Any other duties as assigned to ensure Member care transitions are successful.





Possession of a Bachelor’s degree required, from an accredited four-year institution, preferably in social work or a related field.  Possession of a valid California Driver’s license and proof of current automobile insurance. 



Minimum of three (3) years experience performing or facilitating social work or related services in a community-based setting or Managed Care environment preferred.  Experience in discharge planning preferred.


    Knowledge/Skills Required:

Ability to conduct interviews with Members and their families both telephonically and face-to-face to assess and review their healthcare status and needs. Skillful at offering information and education to Members and their families. Knowledge of community resources. Knowledge of Medicare and Medi-Cal benefits and eligibility criteria.  Maintain strong working relationships with all IEHP internal departments to facilitate interdepartmental communication and coordination as needed.


Starting Salary: $38,438  - $49,004  

Pay rate will commensurate with experience


Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles

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