Lead Transition Coach

Locations: Tarzana and Santa Monica

Start date: January 1, 2022 or after

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
  • Monitor all field coach caseload
  • Making recommendations of any footprint refinements to meet program goals.
  • Maintain accurate data for billing and program compliance

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.
  • Understand and complete all requirements to be credentialed in hospital or health care payor system.
  • Using motivational interviewing as well as educational and transition coaching tools to conduct hospital visits (as applicable) and prepare client for a home visit.
  • Prepare for and conduct post-discharge visit in the home within 48 hours of discharge.
  • Perform in-home or telephonic assessment, HomeMeds (as applicable), and create care plan (as applicable) based on health care contract and scope of work. 
  • Perform timely care coordination follow up calls based on intervention being provided.
  • Identify support systems for the client including timeliness of primary care physician visit, especially after hospitalization.
  • Assist in development of a community-based referral network.  Organize, coordinate and conduct reviews of community resources and social service agencies and other psychosocial referral sources for clients.
  • Develop and maintain automated or manual systems and procedures to facilitate on-going program operations.
  • Participates as an active team member in care transitions with internal and external team members.
  • Identify, assess and respond to crisis situations in a timely fashion, with appropriate interventions.
  • Observe all legal, departmental, health plan and/or hospital regulations.
  • Maintain community relations develop and maintain positive community interactions; build referral relationships in the community and seek new resources.  

This position requires extensive travel locally for Hospital and home-based transition coaching or other home-based programs. Most work is conducted remotely in applicant’s home. This position requires reliable means of transportation and insurance and may require certain vaccinations or screenings.

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