The role of the Transitions Coach is one of client advocacy, empowerment and education.
Bachelor’s degree in social work, psychology, counseling, rehabilitation, gerontology or sociology.
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.
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.
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 firstname.lastname@example.org.