Transitions Coach Social Worker

Job Title : Transitions Coach Social Worker

Reports To :  Supervisor of Network

FLSA Status : Hourly/Non-exempt

Location : San Fernando Office and remote

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

  • 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.


  • 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
  • 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 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.

Partners in Care reserves the right to alter the remote work arrangement at any time with or without notice.