Transitions Coach / Social Worker – Kern County

Job Title: Transitions Coach Social Worker

The role of the Coach Social Worker is one of client advocacy, empowerment and education.

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.

Location: Based in Kern County


  • 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
  • Maintain effective interpersonal communication skills by:
    • open and accurate verbal and written communication.
    • recognize and resolve conflicts or unusual situations.
    • maintain positive interpersonal relationships and team build within department and ancillary staff.
    • complete written correspondence and documentation in a timely manner.
  • Maintain professional work habits by:
    • organize workload and set appropriate priorities.complete assignments within required time frames.
    • maintain client files that are up to date and accessible.
    • use resources appropriately.
    • demonstrate efforts to comply with department/program expectations and productivity standards.
    • demonstrate initiative by seeking involvement in activities beyond routine.
    • demonstrate positive attitude and behavior in accepting and adapting to change.

Physical Demands:

This position requires extensive travel locally for Hospital and home-based transition coaching. Most work is conducted in clients home. This position requires reliable means of transportation, active and clear California drivers  license and proof of auto liability  insurance.

“EOE/Minorities/Women/Veterans/Disability/Gender Identity/Sexual Orientation”