Transition Planner

Job Description

Job Description

Transforming the lives of those affected by severe mental illness

At Amae Health, we are dedicated to helping the 15.4 million Americans living with severe mental illness (SMI) lead stable, meaningful lives, while ending the cycle of repeat hospitalizations. In partnership with some of the nation's top academic medical centers we've pioneered an innovative outpatient care model that combines compassionate, in-person psychiatric care with comprehensive wraparound support. Our integrated care teams — including psychiatrists, therapists, primary care physicians, health coaches, and peer support specialists — work together to treat the whole person via a unique model, addressing physical, mental, and social needs in unison. By caring for every aspect of our patients' well-being, we help them not just survive, but truly thrive.

Amae Health is a Series B venture-backed Public Benefit Corporation dedicated to becoming the nation's center of excellence for individuals living with severe mental illness (SMI). Backed by top-tier venture capital firms and strategic healthcare investors, we collaborate with prestigious health systems including NewYork-Presbyterian, Stanford Healthcare, and Cedars-Sinai, underscoring our commitment to fundamentally transforming mental health care delivery at scale.

The Team:

At Amae we are a collective of healthcare operators on a mission to create a radically different patient-first behavioral health care model that truly transforms patient's lives by integrating care delivery, patient experience, cutting edge technology and research. Join a team of operators, builders and technologists from One Medical, Forward Health, Stanford, UCLA, Hinge Health, Palantir, The Four Seasons, and Brightline as we redefine care for the most vulnerable populations - across the nation, at scale.

The Opportunity:

We are growing our presence in Charlotte, NC and are hiring a Transition Planner to support our patients in their care journey. Reporting to the Chief Strategy Officer, and in collaboration with our Clinic Director, Psychiatrists, Primary Care Providers, Therapists, Dieticians and Clinic Care Coordinators, you will work closely with patients to address problems, answer questions, gather and provide information and advice; with the goal of connecting patients to resources and to the community. You will bridge the gaps in our patient's care journeys, meeting patients where they are at - in the hospital, the community and at times in their homes to facilitate and connect them with the care they need.

What You Will Work On:

• Represent Amae Health in the ER, inpatient, and outpatient hospital setting with our collaborating health systems, social workers, and providers to coordinate patient transitions to Amae, ensuring continuity of care as patients begin their care journey with Amae Health
• Provide initial case consultations to patients and families through video, phone, or in-person visits, often in high-pressure, time-sensitive environments. Collaborate with a multidisciplinary team and establish and maintain trust and rapport with patients, families and teammates
• Actively manage and grow enrollment in targeted regions through systematic outreach, ensuring a steady pipeline of patient referrals.
• Evaluate and track the effectiveness of outreach initiatives, pivoting as necessary to meet growth goals.
• Identify leads for service expansion and develop strategies for assigned areas.
• Establish and maintain relationships with community-based resources (e.g., NAMI), and advocate for Amae Health's services.

About You:

A true patient advocate, you excel in using your knowledge of Charlotte's health systems and services to connect patients to the most appropriate resources in order to support their care journeys. Strong communication skills and an inherent ability to build trust are your hallmarks, and you are passionate about initiating, establishing and maintaining relationships with patients and families that are founded on trust and rapport. You are adaptable, flexible and organized, people centered, and excited about the opportunity to be part of a team that is changing how SMI care is delivered in our community.

What You'll Have:

• 1+ years of patient facing experience as a social worker, discharge planner or transition planner in a hospital setting
• A BSW OR MSW degree OR an unrestricted active license in North Carolina as a Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), or Licensed Professional Counselor (LPC) is required
• Knowledge of and familiarity with the mental health and social service systems in the Charlotte area and an understanding of patient rights and a holistic perspective of "health"
• Demonstrated skill and adaptability in working with people from diverse backgrounds in a variety of settings
• Current driver's license, proof of acceptable automobile insurance coverage, and reliable transportation
• Ability to travel 90% of the time to surrounding hospitals and providers
• Comfort working one-on-one or in group settings, with experience facilitating workshops, events or activities
• Excellent communication skills and a strong desire to collaborate with others in a team based environment and community settings
• Organized with strong attention to detail and the ability to navigate and learn new technologies and platforms, familiarity with EHR, CRM systems, Slack and Google Suite desire

What We Provide:

Amae Health is proud to offer a comprehensive benefits package to take care of you now and in the future, focusing on your personal, financial and professional wellness.

• Health Insurance: Comprehensive medical, dental & vision plans
• Employee Assistance Program
• 401(k)
• FSA & HSA savings programs
• Short & long-term disability
• Pre-tax commuter assistance program
• Paid Time Off
• Parental Leave - 12 weeks for birth and non birth parent
• 11 company holidays

Amae Health is committed to fair and equitable compensation practices.

Base salary range for this role is $70,000 - $95,000 per year based on a full-time schedule. Actual compensation packages are based on several factors that are unique to each candidate. These factors include, but are not limited to, job related knowledge and skill set, depth of experience, certifications, degrees, licensures, and specific work location.

More About Amae:

'Amae', pronounced ' Ah-mai' , is a Japanese concept meaning the need to be in good favor with, and the ability to depend on, the people around oneself. It reflects our core belief that a strong support system is essential to build people up, strengthen their will to carry on and even to thrive in life. This mentality applies across our whole company – from the patients we serve to the team we're building.

We're a Public Benefit Corporation (PBC) that provides outpatient psychiatric and primary care health services through value-based care arrangements. Our model's success is predicated upon achieving outcomes for our patients, not on the volume of services provided.

Amae Health is an equal opportunity employer and encourages all applicants from every background and life experience to apply.