Transition & Case Management Specialist

The Transition & Case Management Specialist (TCMS) works to identify eligible participants and ensure their safe transition from skilled nursing facilities to community living or prevent placement into skilled facilities. The TCMS assists individuals who are currently residing in the community who are at risk of institutionalization and those in institutions wishing to move back into community living by providing support and connection to home and community based services to prevent hospitalization and or institutionalization. The TCMS works as a member of the Choice in Aging (CiA) team providing health and social services to frail elders and adults with disabilities to meet CiA’s mission to create opportunities where people can learn, grow and age independently with dignity in community.

Essential Job Functions

• Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.

Job functions include but are not limited to the following:

• Works collaboratively with health plans to coordinate transition and diversion services.
• Conducts outreach to hospitals, nursing homes, and other medical and residential facilities to identify individuals who want to transition into the community.
• Conducts outreach to senior centers, Information & Assistance programs, Meals on Wheels and other community based services to identify people who need support remaining in the community.
• Participates in outreach and marketing community events.
• Using a person-centered approach, interviews participants to ascertain immediate and long-term needs for services.
• Develops participant-driven transition/diversion plans in consultation with licensed care professionals, care team and others identified by participant.
• Facilitates and leads transition/diversion from medical and residential care facilities.
• Liaisons with community agencies in Contra Costa, Solano and Sacramento Counties to arrange ancillary community-based long-term services and supports.
• Assesses what is needed for a successful transition/diversion, determines most appropriate funding source(s), e.g. health plan, Department of Rehabilitation transition/diversion, Community Living Fund, APS, Measure X, or other community resources or grants to aid in the transition/diversion coordination.
• Enters participant’s demographics and service activities into a database as part of the monitoring and evaluation process and maintains accurate and timely records.

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Minimum Qualifications

• High School Diploma or equivalent with 4 years related experience in area of social science, healthcare, aging and adult populations.
• Bachelor’s degree preferred in area of social science, healthcare, gerontology, or similar social service field.
• Experience working with people with disabilities and/or older adults.
• Must have valid CA Driver’s License and current auto insurance.
• Must pass Live Scan fingerprint background and DMV check.

Job Type: Full-Time (40 hours per week).

Monday-Friday (Closed on most major holidays).

Hourly Rate: $26.00 - $28.00 per hour, depending on experience.

Benefits

Staff working Full-Time (30+ hours per week) are eligible for the following:

• Medical, dental, and vision insurance. Dental and vision insurance free if medical is waived. Medical cost of only $150 per month for employees.
• 20% off tuition at our on-site Montessori preschool, Choice in Learning, if space available.
• Voluntary Illness and Accident Protection (Aflac).
• EAP & 403b Retirement Plan.
• Floating holiday.
• Birthday holiday.
• Generous Paid Time Off (PTO) policy. Staff working 40 hours per week can earn 17 days of PTO per year.
• PTO on most national holidays.

Additional Benefits For Full-Time Employees

• Life Insurance and Accidental Death & Dismemberment Insurance.
• Long Term Disability.

Please Note

Being fully vaccinated means that an individual is at least two weeks past their final dose of an authorized COVID-19 vaccine regimen. Final candidates must be fully vaccinated as of their first day of employment.

Application: Email resume and cover letter to: ***email_hidden*** Subject Line: *Title of Open Position* Note: The recruitment timeline for this position may vary and depend on many factors, and we appreciate your patience during this process. Due to the high volume of applicants, we will only be contacting those candidates whose qualifications most closely match our requirements for the position. No phone calls please. Visit to learn more about Choice in Aging. Choice in Aging is an Equal Opportunity Employer.

About Choice In Aging

Choice in Aging (CiA) has been providing services to the community’s frailest people since 1949, when it was created by volunteers to serve children severely disabled by Polio. Over the years, the organization has provided a wide variety of programs, with the goal of promoting dignity and independence of people with disabilities and special needs. Our mission is to create opportunities where people can learn, grow, and age independently with dignity in community. Program History Adult Day Health Care (ADHC) is a program that was created in California in 1978 in response to a need to have an alternate solution to institutionalization. The program mirrors the skilled nursing staffing model, but is based in the community and typically operates during the day on weekdays. It is akin to a senior center for those who can no longer attend a senior center independently. It is especially beneficial for those who need additional support to do things like ambulate, eat, toilet, participate in activities and more. Staff provides therapeutic activities disguised as fun throughout the day, making socializing and exercising meaningful and pleasurable. This makes folks want to come back each day!