Lead Transition Coach

Title: Lead Transition Coach

Locations: Tarzana and Santa Monica

Partners in Care Foundation is growing and we are looking for a Lead Transition Coach to join our Network Services Department.

Education: Bachelor’s degree in social work, psychology, counseling, rehabilitation, gerontology or sociology preferred

Experience: Minimum of one year required in healthcare and/or community-based adult/people with disabilities focused social work preferred

Special Knowledge, Skills, and Abilities: Knowledge of community-based programs. Ability to work with multidisciplinary team, clients, and their families in home settings.

  • Negative TB test are required
  • One year in an acute care hospital environment required
  • Understanding of hospital dynamics required

Main Responsibilities

  • Station as lead in hospital
  • Manage all referral process including identifying qualified referrals
  • Conduct all hospital visits
  • Determine Care Transitions Choices intervention
  • Assign cases to field coaches
  • Maintain relationship with hospital care managers
  • Attend workgroup meetings and other meetings as assigned
  • Submit daily, weekly, monthly and quarterly reports

Additional Responsibilities:

  • Management of client’s transitioning from the acute/sub-acute hospital or Skilled Nursing Facility setting back to their home or client’s identified by health care payor in needed care coordination/short-term care management.
  • Management of client’s referred by payor.
  • Perform in-home or telephonic assessment, HomeMeds (as applicable), and create care plan (as applicable) based on health care contract and scope of work. 

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.