Part Time Transition Coach – San Bernardino/Inland Empire

Job Title : Part Time Transition Coach – San Bernardino/Inland Empire

Start date: January 1, 2022 or after 

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

Experience: Minimum of one year required in healthcare and/or community-based adult focused social work. Special Knowledge, Skills, and Abilities: Knowledge of community-based programs. Ability to work with multidisciplinary team, clients and their families in home settings.


  • Management of client’s transitioning from the acute/sub-acute hospital or Skilled Nursing Facility setting back to their home.
  • Understand and complete all requirements to be credentialed in hospital system.
  • Using motivational interviewing as well as educational and transition coaching tools, conduct at least one hospital visit and prepare client for a home visit.
  • Prepare for and conduct post-discharge visit in the home within 48 hours of discharge.
  • Perform care coordination follow up calls.
  • Identify support systems for the client including timeliness of primary care physician visit 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 

Physical Demands:

This position requires extensive travel locally for Hospital and home-based transition coaching.

This position requires reliable means of transportation, active and clear California driver’s  license and proof of auto liability  insurance.

If you are interested in this position, please submit your resume to