Job Description

Job Title: Transition Care Coordinator (MSW)
Job ID: 729398
Status: Full-Time
Regular/Temporary: Regular
Hours: Monday - Friday, 8:30 a.m. - 5:00 p.m.
Shift: Day Job
Department: POP18 PEDS Adolescent
Location: 3420 Fifth Avenue, Pittsburgh PA 15213


The outpatient Transition Care Coordinator (TCC) for the Division of Adolescent and Young Adult Medicine is responsible for coordination of interdisciplinary assessment, counseling, referral, and advocacy based on the needs of adolescents and young adults with complex health needs (AYA) as they transition from childhood to adulthood. Orient and educate staff, patients and families to the role of the TCC.

  • Demonstrate knowledge of reimbursement systems, the ability to train patient and families regarding payer requirements/coverage for outpatient services and individual's responsibilities regarding maintenance of health care coverage.
  • Educate and advocate for patient and families to enhance their ability to make informed decisions regarding medical care.
  • Effectively coordinate the identification, assessment, and counseling of individuals who have medical and psychosocial complex needs. o A complete assessment includes social, economic, cultural, age/development related behavioral factors, history of child, elder or domestic abuse, prior psychiatric or substance abuse treatment, family and social support systems, and all other available resources. o Coordination of counseling includes communication with collocated, intra-system, and community-based therapists and professionals.
  • Foster peer support and community engagement for individual AYAs.
  • Initiate and collaborate with the healthcare providers, patients and families, and relevant community resources to develop and implement an individualized interdisciplinary care plan.
  • Maintain extensive knowledge of federal, state and local assistance programs and community resources that affect patient needs; demonstrate expertise in accessing social systems by providing resource-specific information to patients/families, initiating contact with resources and facilitating the patient's / family's ability to accept referrals.
  • Monitor and evaluate the plan, options, and available services to effectively meet the patient's needs. Reassess the plan of care as status changes.
  • Orient and educate staff, patients and families to the role of the TCC.
  • Participate in Interdisciplinary Quality Improvement projects and Case Conferences. o As skills develop, expectations will include leadership roles in QI projects
  • Participate in crisis assessment and utilize the modalities of crisis intervention, including brief goal-directed therapy or other therapeutic counseling methods.
  • Performs duties and responsibilities in accordance with the philosophy and standards of UPMC, including conveying courtesy, respect, enthusiasm, and a positive attitude through contacts with staff, health plan members, peers and external contacts.
  • Practice effective advocacy on behalf of patients to obtain authorization for services, while promoting the development of self-advocacy skills.
  • Provide accurate, timely and appropriate documentation of all social work care coordinated services the medical record per regulatory policies and procedures.
  • Provide education to AYA regarding the case management process as indicated.
  • Provide follow-up and assess effectiveness of services after individuals have transferred from our clinical services.


  • Master's degree in Social Work
  • One (1) year of experience working with vulnerable youth required


Licensure, Certifications, and Clearances:

  • Act 31 Clearance
  • Act 33 Child Clearance with Renewal
  • Act 34 Criminal Clearance with Renewal
  • Act 73 FBI Clearance

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $18.53 to $30.32

Union Position: No

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