Transitions Coordinator

The Transitions Coordinator works with the Executive Director or designee and the Aging & Disability Resource Connection (ADRC) staff to assist people with disabilities who want to relocate out of an institutional setting (nursing homes, acute care facilities, etc.). In addition, the Transitions Coordinator will assist people with disabilities to remain in their own homes (diversion) and assist youth with disabilities in their efforts to transition into adulthood. The Executive Director or designee supervises this position. The Transition Coordinator facilitates service coordination for those residents who choose to relocate from an inpatient facility to community-based living (such as their own apartment). The Transitions Coordinator, in cooperation with the inpatient facilities project nurse, discharge planning staff, and regional transitions team, are responsible for linking the person with a disability to all supports to ensure all services are in place to discharge. The Transition Coordinator will be responsible for the following activities

• Work directly with nursing facility residents, their families, physicians, service providers and discharge nurse to develop a comprehensive care plan.
• Establish and maintain a working relationship with nursing facility and hospital staff, long-term care ombudsmen, social services staff, Medi-Cal eligibility staff, state and federal agency staff (e.g., Social Security Administration), IHSS staff, and others.
• Create linkages between inpatient facility residents & services, community agencies, housing programs, and other resources necessary for a safe and successful transition.
• Coordinate discharge from the inpatient facility with various programs and services necessary to complete a safe and successful discharge.
• Coordinate referrals by agencies that provide medical services, social services, Medi-Cal eligibility, housing, transportation, and others as appropriate for preliminary care-planning.
• Assist residents with paperwork, deadlines and record keeping as needed.
• Schedule meetings and consultations with individuals, groups or agencies that can provide input regarding preliminary care coordination.
• Communicate with resident to determine preferences and apprised of the transition progress.
• Keep all consumer medical information and case records confidential.
• Keep accurate individual service coordination records and reports.
• Work with Deputy Director to monitor and submit e-TARs via the Internet.
• Work with Deputy Director to monitor and submit medical billing via the internet.
• Schedule assessment Interviews and conferences with residents and their significant others.
• Work with youth with disabilities to create a budget and locate affordable and accessible housing.
• Assist people with disabilities in locating alternative options, such as home modifications, to keep them living in their own homes and away from an institutional setting.
• All other duties as assigned by supervisor.

• Must be able to decipher the difference between Independent Living and a Homeless Crisis, while applying the Independent Living model.
• Communicate professionally with the general public and professionals in a variety of arenas including health care providers and social services agencies.
• Exercise diplomacy, tact and good judgment.
• Exercise residents’ rights to privacy and adherence to HIPAA guidelines.
• Demonstrate clear oral and written communication skills.
• Demonstrate knowledge of and working experience with community-based organizations, and long-term care programs.
• Knowledge and insight to working with elders and persons with disabilities.
• Knowledge of general medical terminology and care plans.
• Demonstrate the knowledge of working with Windows environment including the ability to use word processing, internet, and encrypted e-mail.
• Must have own transportation with clean driving record to implement home set-up for consumers., * At least four years of college, vocational school, certification training or equivalent in a related field (health, nursing or human services). Life and work experience with long-term care programs, home and community-based services, and programs serving seniors and/or persons with disabilities may be substituted.
• BA degree in gerontology, social work, long-term care, health care management, or related field.
• Experience serving seniors with mental, physical and/or functional impairments.
• Experience in understanding general Medi-Cal and/or Medicare benefits.
• Experience in Long-term care services and care plan development.
• Experience in inpatient facility discharge planning.

PHYSICAL AND EMOTIONAL DEMANDS: The physical demands of the position reflect the duties listed above, and are essential for the employee to perform. Must be able to move and unload small to medium size items for home set-up (microwave, chairs, end table, etc.) Must be able to move small consumer items into their new residence (pictures, clothes, personal items, etc.) Must be able to remain in a seated position for an extended period. Must be able to operate a computer, key board, phone, and monitor for an extended period. Constantly operates a computer and other office machinery, such as a calculator, copy machines, fax machine, and printers. The emotional and stress demands of the position reflect the duties listed above, and are essential for the employee to perform. Must be able to handle moderate to high levels of stress during times of consumer transitions and high call volume. Communication and behavioral styles vary, and the employee must be able to adjust with these styles during transitions period and reporting deadlines.

POSITION: Non-exempt position. $23.00 to $28.00 per hour. Benefits include paid holidays, sick leave, vacation leave, medical benefits package, and 37.5 hour workweek., * Dental insurance

• Health insurance
• Paid time off
• Vision insurance