Transitions of Care Manager

Community Health Plan of Washington

Transitions of Care Manager managing pre-release planning and short-term case management for justice involved members. Working with multi-functional teams to connect individuals to health resources for successful reentry.

Posted 7/10/2026full-timeSeattle • Washington • 🇺🇸 United StatesMid-LevelSenior💰 $36 - $56 per hourWebsite

About the role

Key responsibilities & impact

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.

Requirements

What you’ll need

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.

Benefits

Comp & perks

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.

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

Case ManagementHealth AssessmentResource CoordinationDischarge PlanningDocumentation StandardsTelehealth CommunicationCare Plan DevelopmentCrisis InterventionBehavioral Health SupportCultural Competency

Soft Skills

AdvocacyCollaborationCommunicationEmpathyProblem-Solving

Certifications

National Provider Identifier (NPI)Washington State Medicaid ProviderOne Registration