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. 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. Choice in Aging is an Equal Opportunity Employer. #J-18808-Ljbffr