CASE MANAGER (LCSW) TRANSITION OF CARE

Responsibilities

FHCHS of PR, Inc. organization with extensive experience in managing mental health benefits and developing solutions that promote the emotional well-being of individuals, families, workplaces, and communities.

Since our foundation in 1996, at FHC Mental Health, we have worked to facilitate access to excellent mental health services and support people at different stages of their lives.

Our experience has allowed us to evolve, expand our services, and develop integrated solutions that promote prevention, guidance, recovery, and continuity of care.

Website: fhcsaludmental.com

Position Summary

The Transition of Care Coordinator oversees the daily operations of the Mental Health Transitions of Care Program and ensures the effective coordination of behavioral health services following discharge from inpatient settings.

This includes reviewing discharge plans, monitoring members at risk for readmission or disruption of care, ensuring timely follow-up appointments, facilitating communication among healthcare providers and caregivers, supporting medication reconciliation, and coordinating crisis interventions when clinically indicated.

The Transition of Care Coordinator also promotes person-centered, trauma-informed, culturally responsive, and recovery-oriented care to support successful transitions and continuity of treatment.

Job Duties/Responsibilities

Identify individuals who meet the criteria for the Transition of Care program in the behavioral health inpatient census, review ongoing hospitalizations, and discharges to facilitate patient’s safe transition between care settings. Coordination with inpatient facility teams to track clinical status, readiness for discharge, social determinants of health and address barriers that may impact successful transitions and care continuum.

Managing staff assignments, caseload distribution, scheduling, productivity expectations, and workforce performance. Develops and updates workflows and standard operating procedures; prepares reports and presentations on program outcomes and trends for organizational leadership; and performs other duties necessary to support the effective operation and success of the Transitions of Care Program.

Assure documentation of all Transition of Care strategies, internal and external coordination, assessments and meaningful interactions with patients and their healthcare providers to achieve a successful transition and compliance with quality measures, accreditations and regulatory requirements.

Assess and monitor risks related to readmission, relapses, medication non‑adherence, and deterioration in mental health status during the transition period.

Interventions include transitional care planning, education on diagnoses and treatment, identification of early warning signs, crisis prevention strategies, social determinants of health and facilitation of continuity support within the community setting.

Assures referrals and coordination to community‑based resources and physical health services to address identified needs and support continuity of care.

Communicates timely with health plan, primary care providers and behavioral health providers, community organizations and internal departments, including Utilization Review, Quality, Pharmacy, and Behavioral Contact Access Center, to ensure coordinated, member‑centered transitions.

Serves as the liaison between Contact Center, Community Outreach Mental Health Workers and Transition of Care staff working collaboratively to reduce unable to contact members. Provides referrals of cases to Outreach Community Mental Health Workers and Case Managers, as necessary.

Responsible for maintaining program quality and regulatory compliance by reviewing cases against clinical guidelines, organizational policies, contractual requirements, and accreditation standards. Responsibilities include monitoring key performance indicators such as post-discharge follow-up, readmission rates, and continuity of care; conducting case reviews and interdisciplinary meetings; identifying gaps in care; implementing corrective actions and process improvement initiatives; auditing documentation for quality and compliance; ensuring adherence to HIPAA and behavioral health confidentiality requirements; and participating in internal and external audits and corrective action planning.

Actively participates in interdisciplinary care team (ICT) meetings and case discussions, applying integrated care models to monitor member outcomes and optimize service delivery. Maintains timely availability to clinical and non‑clinical staff for consultation. Access includes availability of the same day availability for urgent consultations and availability within two business days for routine matters. Participate in team and interdepartmental meetings as required.

Perform other duties assigned by supervisors that contribute to program goals and support community mental health service coordination. Be prepared to travel within Puerto Rico to fulfill job responsibilities as necessary.

• Benefit & Rewards Highlights
• Competitive Compensation
• Excellent Medical, Dental, Vision and Prescription Drug Plans
• 401(K) with company match
• Career development opportunities within UHS and its 300+ Subsidiaries!
• Tuition incentive
• Continuing education incentive
• Vacation and sick license, among others.

About Universal Health Services

Headquartered in King of Prussia, PA, Universal Health Services, Inc. (NYSE: UHS) is one of the nation’s largest and most respected providers of hospital and healthcare services.

Since our founding in 1979, UHS has grown steadily into a premier Fortune 500® corporation perennially recognized by multiple esteemed national rating entities.

Through its subsidiaries, UHS operates inpatient acute care facilities, inpatient behavioral health facilities, outpatient and other facilities, nationwide virtual behavioral health services, an insurance offering, a physician network and various related services with physical locations in the U.S., Puerto Rico, Ireland and United Kingdom. uhs.com.

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Qualifications

Master’s in social work, Psychology, Psychological Counseling, Mental Health Counseling, or Psychiatric Nursing

Valid and current active license for Social Work, Psychiatric Nursing, Psychological Counseling, Psychology, or Mental Health Counseling

• Professional associating membership (colegiación): valid membership for Social Work and Psychiatric Nursing
• Twoo or more years of experience in the health field.
• Knowledge in Microsoft Office
• Preferred fully bilingual

EEO

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

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At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries.

During the recruitment process, no recruiter or employee will request financial or personal information (e. g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc.

If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters