TITLE: NURSING HOME TRANSITION (NHT) - TRANSITION COORDINATOR
DEFINITION : Reporting to the Nursing Home Transition Supervisor, the Transition Coordinator for the Nursing Home Transition Program will be responsible for coordinating transition services to enable individuals to be discharged from nursing facilities back into the community. Services available include assessment, service planning, case conferences, training, transition management, monitoring, and post-transition advocacy and follow up. Responsibilities are carried out in accordance with policies and requirements of the individual’s Managed Care Organization (MCO).
QUALIFICATIONS:
Education:
§ BSW or related degree
Experience :
§ BA/BS/BSW candidates require three years social work or related experience.
Personal Characteristics :
§ High energy level; able to manage a variety of tasks simultaneously.
§ Strong interpersonal and communication skills.
§ Well organized.
§ High level of flexibility.
§ Possesses advocacy skills and a sense of professional ethics.
Additional Requirements:
§ Must have valid driver's license, a good driving record, and continuous access to a fully-insured car.
§ Pre-employment physical.
§ Drug testing.
§ Criminal history clearance.
§ Second language abilities preferred.
§ Knowledge of disability and aging issues, resources and service networks.
GOALS:
To successfully identify and transition long-term care facility residents into community based settings.
DUTIES AND FUNCTIONS:
a. Works with Managed Care Organizations (MCOs), community-based service agencies and long-term care facilities regarding identified candidates.
b. Travels throughout service area (Philadelphia and the surrounding counties) to meet with individuals identified as appropriate for community living, as well as with family members, service providers, and other stakeholders.
c. Interviews and discusses program with individuals who desire transition services. Confirms eligibility, reviews both informal and formal supports, and discusses options.
d. Utilizing strengths-based and person-centered planning approaches, assesses individuals to determine appropriate referrals for service, including evaluation, documentation and follow up.
e. Plans and coordinates relocation efforts with participant, family, facility and community based service providers.
f. Plans and implements or coordinates community integration activities with participant to increase independence, such as mobility and skills training and other community supports.
g. Works with service providers to assure instruction desired or needed by participant in areas such as financial management, household management, cooking, mobility, and decision-making is provided.
h. Monitors quality of service and participant satisfaction to ensure successful transition.
i. Recognizes supports, develops, and mobilizes informal and formal resources to meet participants’ unmet needs, as well as focusing on participants strengths.
j. Processes NHT funding for participants through their assigned MCO.
k. Collaborates with IEB, CAO, and assigned MCO to assure timely enrollment and service delivery for participants.
l. Attends and participates in meetings with long term care facilities and the assigned MCO staff.
m. Completes all necessary data entries and documentation with the assigned MCO system/procedures within same day/next day timeframe.
n. Solicits assistance from non-traditional services to facilitate persons transitioning, such as volunteers and in-kind contributions.
o. Provides data as needed for reporting and accountability to the assigned MCO.
p. Transports participant to necessary appointments to secure required documents (i.e. proof of income, PA ID, and/or Social Security card.
q. Transports participant and his/her personal belongings for transition from long term care facility and transition preparation (i.e. shopping).
r. Monitors quality of service and participant satisfaction to ensure successful transition
s. Participates in orientation and training, in-service training as assigned, and attends
regular team and staff meetings.
t. Other duties as assigned.
PERFORMANCE EXPECTATIONS:
CUSTOMERS:
§ Residents of long-term care facilities
§ Caregivers of adults in need of long-term care services.
§ Managed Care Organizations
§ Service providers.
§ IEB
§ CAO
SALARY $46,788.42