Maryland Care Management Inc·Baltimore, Maryland
The TOC Social Worker supports high-risk members transitioning from hospitals or facilities back to the community by addressing social barriers and coordinating care. Responsibilities include conducting assessments, developing care plans, and collaborating with interdisciplinary teams to ensure safety and stability.
Description *This position will be doing home and facility visits in Baltimore 4-5 days/week*
The Social Worker on the Transition of Care (TOC) team supports high-risk members at a critical point in their care by addressing complex social barriers and helping guide a successful return to the community following hospitalization. Working collaboratively with facility case managers, nurses, and an interdisciplinary care team, the TOC Social Worker provides short-term, high-impact interventions focused on stabilization, safety, and connection to community resources. You will meet members where they are—often face-to-face—and use clinical judgment, motivational interviewing, and problem-solving skills to support recovery, independence, and continuity of care. About Maryland Care Management, Inc. (MCMI) Maryland Care Management, Inc. (MCMI) manages Maryland Physician Care's (MPC) statewide provider network of hospitals and physicians. Maryland Physicians Care has been providing services to the HealthChoice Medicaid populations since 1996, and we are proud of our footprint in the community. With over 230,000 members, MPC consistently has been one of MD's largest Medicaid-managed care organizations.
MCMI recognizes the importance of flexibility and offers multiple work arrangements.
Along with competitive pay, we offer excellent benefits (medical, dental, and vision plans, 100% employer Term Life Insurance, Short and Long-Term Disability, 401k Employer Match up to 4%) as well as 20 days of PTO, and tuition assistance/professional development plans.
Your future colleagues at MCMI are welcoming, friendly, and eager to help each other succeed.
We are committed to Diversity, Equity, and Inclusion, providing organizational-wide social opportunities, and constantly improving our ongoing efforts to positively impact our members' lives.
Evaluate members based on their needs and limitations based on referrals. Will work directly with the Hospital/SNF case management staff to assist with the coordination of care and discharge plans for identified members. Will collaborate directly with members and their families to build a rapport to assist with discharge needs as appropriate. Address member concerns and goals while maintaining constant communication with the member. Utilizes clinical judgement to assess members, prioritizing emerging issues to maintain a member-centric approach. Collaborates with interdisciplinary care team at the facilities to support member health goals via conference calls, rounds, and consultation, which may include face-to-face meetings. Complete assessments to better understand the Social Determinants of health and social issues impacting member care goals. Utilizes problem-solving skills to research and identify community resources and coordinate a referral mechanism. Plans specific objectives, goals, and actions designed to meet the members’ needs as identified in the assessment process that are action-oriented, time-specific, and cost-effective. Implements specific activities and/or interventions that lead to accomplishing the goals outlined in the plan of care. Develop trusting relationships with members by providing support and advocacy to help achieve health goals. Monitors care management activities, services, and members’ responses to interventions, to determine the effectiveness of the plan of care and the utilization of services. Evaluate the effectiveness of the plan of care in reaching desired outcomes and goals; makes modifications or changes in the plan of care as needed. Make connections with members through visits to the hospital, home, and community via face-to-face, telephonic and/or video conferencing. Participates in outreach activities to promote knowledge of the program and its services and to coordinate program activities with outside community agencies and health care providers. Work with the MPC Case Management Team for an appropriate transition of care.
Secondary
Functions: Observe confidentiality of member records in accordance with MPC policies and procedures. Possession of a valid MD State Driver’s License.
Knowledge and Skills: Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community. Knowledge of community agencies and resources. Working knowledge of multi-system outreach programs related to health care delivery, clinical education, and health-related services. Ability to plan, implement, and evaluate individual member care plans. Knowledge of change management, behavioral change management, transportation/food/safety resources. Education and Work Experience: Master’s degree in social work. Maryland state LMSW/LCSW or LCSW-C licensure. At least 1 yr experience in a community-based, hospital, or discharge planning setting addressing social needs and care transitions. Knowledge of government-managed care programs preferred.
Following applicable federal, state, and local laws, MCMI prohibits discrimination in employment based on race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, genetic information, or any other characteristic protected by law. This commitment extends to all aspects of employment, including hiring, promotion, compensation, benefits, training, social and recreational programs, and all other conditions and privileges of employment. As a healthcare organization, we recognize the vital importance of inclusivity in delivering quality care to our patients. We strive to foster an environment where individuals of all backgrounds feel respected, valued, and supported. We aim to better comprehend the unique needs of our patients and provide healthcare services that are culturally competent and sensitive. We encourage candidates from all backgrounds to apply and join us in our mission to provide compassionate and inclusive healthcare. We believe that a diverse workforce enriches our organization and allows us to better understand, connect with, and serve our diverse patient population.
Market context
In Maryland, physician openings are typically shaped by steady demand across hospitals, outpatient practices, and specialty care settings, especially for candidates who can work in person and coordinate with care teams. These roles are competitive because employers often look for strong communication skills, active licensure, and readiness to meet facility-specific expectations; the job requirements and benefits here are AI-summarized from the original posting, saving you research time. Before applying, confirm the license type, site location, and whether the listed benefits align with your needs.
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