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.
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”