Social Work Care Transition Specialist

Baltimore, MD
Full Time
Mid Level

About SilverStay

SilverStay is on a mission to be the leading healthcare services company nationwide for complex discharges by 2030. We provide solutions for medically and financially complex clients who are failing at home or transitioning out of the healthcare system. Our guideposts — Empathy, Creativity, Collaboration, and Ethical Conduct — mean we're not just providing solutions, we're changing healthcare.

About the Role

This is an embedded Care Transition Specialist role, physically based at the University of Maryland Medical System in Baltimore. You will serve as SilverStay's on-the-ground presence — managing contract cases from referral through discharge, conducting bedside visits, coordinating ALF tours, and ensuring every transition closes cleanly. You'll work directly within hospital systems (including EPIC), giving you real-time access to patient notes and the ability to act fast when cases evolve.

This role was designed for someone who has been here before — who knows how hospital discharge planning works, can manage 10–15 active contract cases simultaneously, and thrives in a high-pressure, fast-moving environment. You will not be starting from scratch; you'll be stepping into an active book of business with a team behind you.

What You'll Do

• Own Contract Cases End-to-End: Manage the full contract case lifecycle — referral intake, options sourcing, family outreach, bedside visits, ALF coordination, and discharge follow-through.
• Stay Ahead in EPIC: Access and monitor EPIC (and other hospital EHR systems) to stay current on patient status, updated notes, and clinical changes — proactively, not reactively.
• Manage an Active Caseload: Handle 10–15 active referrals at any given time, maintaining thorough and timely documentation in SilverStay's CRM.
• Be Present Where It Counts: Conduct in-person bedside visits and attend ALF tours when needed; weekend availability is a real expectation for this role and will be set as such upfront.
• Serve as SilverStay's On-Site Liaison: Build trusted working relationships with case managers, social workers, and discharge planning teams at University of Maryland.
• Support the Broader Team: Handle the volume of requests that come directly from the hospital — inquiries, logistical coordination, referral follow-up — so the broader team can stay focused on tours and sourcing.
• Collaborate & Follow Through: Work closely with the SilverStay Baltimore team, share case updates, escalate complex situations, and provide ongoing follow-up with clients and families for a minimum of 30 days post-transition.

Who You Are

• Active Maryland Social Work license (LCSW or LCSW-C) — strongly preferred
• 3+ years of experience in hospital discharge planning, care transitions, or a closely related clinical-social work role
• Hands-on familiarity with hospital EHR and care coordination systems (EPIC experience is a plus; comfort learning new systems is a must)
• Demonstrated ability to manage complex, fast-moving caseloads with multiple stakeholders — families, hospitals, ALFs, payers
• A track record of placing 2+ clients per week in appropriate care settings
• Strong emotional intelligence — able to navigate high-stress family dynamics with calm, empathy, and decisiveness
• Local to Baltimore with reliable transportation, a valid MD driver's license, and genuine availability for in-person work including occasional weekends
• Self-directed, responsive, and organized — you own your caseload and don't need to be managed step-by-step

Why You'll Love It Here

• High Impact: Your work directly shapes how complex patients leave the hospital — and how families experience that transition.
• Active Book of Business: You're stepping into a real caseload on day one, with a team and infrastructure already in place.
• Mission-Driven: Every placement represents a family helped and a hospital team supported.
• Recognition & Growth: As SilverStay expands, your dedication will open doors for advancement.
• High-Trust Culture: Low bureaucracy, direct feedback, and a team that respects your expertise and autonomy.

Compensation & Benefits

• This is a full-time W-2 role
• Base Salary: $70,000 – $85,000 depending on experience
• Performance Bonus: Tied to monthly placement volume
• Health, dental, and vision benefits
• Mileage reimbursement at the IRS standard rate for all approved travel

SilverStay is a 2024 Baltimore Business Journal Best Places to Work! Learn more about SilverStay here.