• Authorizes and reviews mental health and substance abuse services • Assists with discharge planning and care coordination • Provides member assistance and monitors services • Develops discharge plans in conjunction with providers • Participates in quality improvement activities

• Primary focus for this new team will entail supporting a growing number of clinical data feeds in our organization. • Build and represent the vision. This role will have high level exposure and require superior communication and presentation skills to deliver insights to stakeholders and team members, including executives. • Identify feature priorities, lead user story definition, partner with cross functional solution delivery teams, and manage the product roadmap. • Gather and monitor key performance metrics to ensure product performance and quality, as well as identify optimization opportunities.

• Manage patients through transitions of care, either face to face in the facility or telephonically, within a defined geographical area and care setting. • Advocate for the patient throughout the care continuum to ensure access to resources and resolution to all barriers to care. • Establish relationships and ensure patient/family are informed of patient condition, plan of care and discharge plan, all discharge instructions, medication reconciliation; rationale of Utilization Management determinations and any financial information associated with such, potential for LTC transition (if applicable) and importance of timely PCP follow-up following discharge. • Identify opportunities for improved program workflows, increased internal and external partnerships, and higher quality patient care. • Maintain real-time and accurate records of patient status through care transitions within Oak Street's internal inpatient platform. • Adhere to CMS, state specific and NCQA compliance criteria as related to Transitions of Care. • Coordinate with the Utilization Management team to review medical and payer records to ensure appropriate length of stay and identify any barriers to discharge. • Participate in regular inpatient and post-acute rounding calls with Care Navigation and Utilization Management teams to help determine patient status and appropriate discharge plan. • Assist Utilization Management team with access to external medical record information (if available) when needed to make appropriate determinations. • Collaborate with other transitions team members (e.g., Transitional Care Managers - RN and Transitional Care Coordinators) to ensure safe discharge and timely follow up. • Communicate and coordinate with internal stakeholders to identify and address patient needs (e.g., care team, social work, behavioral health, utilization management, Hard-to-Reach, Central Telehealth, etc.). • Participate in regular meetings with Oak Street Health regional leaders to coordinate program implementation and ongoing management. • Engage directly with inpatient physicians, case managers, medical directors, social workers, and SNFists (where applicable) to facilitate safe and timely discharge, appropriate follow-up care, and next steps. • Participate in initial and ongoing required training to ensure appropriate implementation of transitions activities and programming. • Follow program procedures for documenting and tracking transitions interventions. • Adhere to CMS, state, and NCQA compliance criteria as related to Transitions of Care. • Other duties, as assigned.

• Coordinate care for members who face multiple chronic medical and behavioral health conditions • Conduct comprehensive assessments to evaluate members’ needs • Address SDoH challenges by connecting members with appropriate resources and support services • Provide education and guidance to members and their families on managing chronic conditions • Develop and implement individualized care plans • Monitor member progress and advocate for necessary services • Collaborate with the interdisciplinary care team to ensure optimal health outcomes • Document assessments and interventions • Participate in team meetings to discuss member status and care strategies