Lead Transition Coach CCT/ALW

Job Title : Lead Transition Coach CCT/ALW

Education: Masters’ degree in Social Work.


Minimum of one years of experience required in coordinating healthcare projects or social service projects.

Two years of experience required in case management, working with seriously ill, frail, or disabled children and adults. Preference for hospital or SNF and HCBS experience.

Special Knowledge, Skills, Abilities: Clinical assessment skills, knowledge of the community, ability to work with multidisciplinary team and to work with clients/families in the home setting.

Main Responsibilities

  • Provide support and guidance to Transition Coordinator and Registered Nurse as it relates to Case Management Team Responsibilities.
  • Review and approval of intake and reassessment packages to ensure Individualized Service Plan (ISP) is person-centered and includes the member’s goals and preferences based on medical need
  • Review and approval of member cost monitoring.
  • Ensure intake and reassessment are completed and submitted within DHCS/PICF timeframes.
  • Facilitate multi-disciplinary meetings as needed to ensure participant medical needs are being addressed to maintain them safely and healthy in the community.
  • Monitor and Submit Incident Reports to DHCS
  • Monitor caseload size and assignments
  • Conduct Member Profile Record Reviews
  • Ensure monthly case contacts are completed
  • Ensure ISP are completed within the designated treatment period.
  • Monitor performance and delegation to field staff
  • Develop Resource Manual
  • Assist with Development of Program Software
  • Complete Program Quarterly Reports due to DHCS
  • Complete Program Monthly Billing
  • Must have excellent communication skills, verbal /written skills, computer/software skills
  • Maintain patient confidentiality
  • Adhere to HIPAA regulations

Additional Responsibilities

  • Establishes partnership relationship with client and family/representatives to elicit goals, preferences and needs for health and independent living
  • Evaluates the potential client as a total person and identifies socioeconomic and psychological challenges that impede independent living
  • Conducts in-depth assessments, reassessments covering psychosocial, rehabilitation, and environmental concerns to determine level of care required
  • Works as part of care management team to provide person-centered planning and services including participation in interdisciplinary planning and case conference meetings
  • Record clinical notes for the client within established program guidelines
  • Arranges community services and monitors quality of care and adherence to approve POT
  • Completes Acuity tool to determine case management level
  • Works with participant, family and caregivers to maximize self-determination and provision of informal services
  • Ensures POT is as self-directed as the participant desires and involve the circle of support as invited or if participant is unable or unwilling to make decisions.
  • Ensure the POT corresponds with the TARS (treatment authorization requests of services) submitted by the Service Providers.
  • Refers clients to special consultants to provide detailed evaluations and recommendations to improve the client’s functional level
  • Supports the waiver program by participating in quality assurance programs including peer review
  • Maintain patient confidentiality
  • Adhere to HIPAA regulations

If you are interested in this position, please submit your resume to jobs@picf.org.

Partners in Care Foundation is an equal opportunity employer.  We are committed to complying with all federal, state, and local laws providing equal employment opportunities, and all other employment laws and regulations. It is our intent to maintain a work environment which is free of harassment, discrimination, or retaliation because of age, race (including hair texture and protective hairstyles, such as braids, locks, and twists), color, national origin, ancestry, religion, sex, sexual orientation, pregnancy (including childbirth, lactation/breastfeeding, and related medical conditions), physical or mental disability, genetic information (including testing and characteristics, as well as those of family members), veteran status, uniformed service member status, gender, gender identity, gender expression, transgender status, arrest or conviction record, domestic violence victim status, credit history, unemployment status, caregiver status, sexual and reproductive health decisions, salary history or any other status protected by federal, state, or local laws.  All qualified applicants will receive consideration for employment and reasonable accommodations may be made to enable qualified individuals to perform the essential functions of the position.