Transitions Coach | Partners In Care Foundation

Transitions Coach

Job Title: Transitions Coach

FLSA Status: Non-Exempt

Location: Culver City

Reports To: Supervisor Health Services

Responsibilities:
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.

Education, Skills, and Competencies
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.

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

The above job description is not intended to be an all-inclusive list of duties and standards of the position. Incumbents will follow any other instructions, and perform any other related duties, as assigned by their supervisor.

Excellent benefits package including medical, dental, vision, life insurance and 401K
EOE/Minorities/Women/Veterans/Disability/Gender Identity/Sexual Orientation

If you are interested in this position, please contact Briana Hathaway at (818) 837-3775 extension 109 bhathaway@picf.org.

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