Mission Statement: Bay Cove Human Services partners with people to overcome challenges and realize personal potential.
Job Summary: The Transition Coordinator is responsible for providing care planning, coordination and collaborates with the respective team and the clinical staff to minimize duplicative efforts, promote integrated care, ensure quality and continuity of care, and support the values of person centered planning. The Transition Coordinator is at the helm of organizing and coordinating resources and services in response to the integrated plan. This role drives outreach and engagement, social needs assessment, LTSS care planning and care coordination, support of care transitions, health and wellness coaching, as well as community and social services connections in partnership with the individuals and their designated care teams. This is a non-exempt position.
Supervisory Responsibilities: N/A
Essential Functions of Position:
- Inform Enrollee of options for specific services, programs, and providers that best meet identified needs
- Identify community and social services to support health and wellbeing of the Individual
- Initiate and follow through on all community based referrals identified by the team
- Support care transitions through collaboration with Individual and their team, community provider staff, natural supports and house staff to ensure a safe discharge plan and a well-coordinated implementation of that plan
- Ensure all Individuals are consistently provided with trauma informed and cultural responsive services
- Ensure timely information exchange, coordination, and integration of care
- Provide the clerical, clinical and operational support for program
- Complete all paperwork Activities as required
- Document all care coordination activities in Individual’s electronic record
- Perform other duties, as required
Typical Requirements:
- Minimum of 3 years case management experience preferred. Effective skills in managing, teaching, and negotiating, and in collaborating with multidisciplinary teams and client/family focus. Experience working with people living with disabilities with complex LTSS and BH needs. Preference given to bi-lingual/bi-cultural applicants and those with lived experience. In some cases, experience may be substituted for academic training.
- A COVID-19 vaccination is a requirement of the position. One COVID-19 shot is acceptable, contingent on the individual receiving the second shot within the allotted time frame.
Education and Required Credentials/Licenses: BA/BS in human services related field is strongly preferred.