Transitions Coach / Social Worker

Job Title: Transition Coach Social Worker

Education: Bachelor’s degree required in Social Work, psychology, counseling, rehabilitation, gerontology or sociology.

Experience: Two years of case management experience with mentally ill, seriously ill, frail, or disabled adults.

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.


  • Provide in home psychosocial assessment.
  • Must evaluate the potential client as a total person and identify the functional limitations, which impede independent living.
  • Conducting in-depth assessments/reassessments covering psychosocial, rehabilitation, and environmental concerns
  • Referring clients to special consultants to provide detailed evaluations and recommendations to improve the client’s functional level
  • Developing the care plan, implementing the services and conducting follow up and monitoring of the plan
  • Provides case management in accordance with departmental policy, program standards and patient needs by:  
    • Completing assessment evaluation of a client’s health and Psychosocial status utilizing all relevant information sources including the identification of issues that are specific to age, diagnosis and disabilities of the client population served, in accordance with departmental policy.
    • Participating as an active team member in care planning to develop care plans specific to the client’s needs.
    • Implementing interventions and services utilizing community resources in a timely fashion in accordance with departmental policy.
    • Maintaining and documenting regular contact with clients in accordance with departmental policy.
    • Identifying, assessing and responding to crisis situations in a timely fashion, with appropriate interventions.

Additional Requirement:

Copy of current automobile insurance provided annually of $15,000/$30,000 for injury and $5,000 for damage to property.