Community Transition Liaison

What You Will Do

• Acts as onsite point of contact for residents, families, health care proxy (HCP) and NF staff related to transitions from NF to community
• Visits with residents to increase awareness of service and introduce transition to the community as a potential option
• Participates in resident, family and/or HCP conversations to inform options and transition planning
• Completes the directional screening tool to determine potential appropriateness for referrals to HCBS Waivers and other programs to support the transition to the community and meet the consumer's needs once in the community setting
• Facilitates person-centered planning and needs assessment
• Begins the process of gathering necessary documentation and identification needed for housing Applications And Other Public Benefits
• Completes referrals to other programs and follows-up on referrals to ensure timely transition
• Participates in Interdisciplinary Discharge Planning (IDP) meetings and facilitates communication among the consumer, family and community agencies
• Participates and facilitates in discharge planning meetings with the consumer, family, nursing facility staff and other agencies that will support the consumer in the community upon discharge
• Captures and coordinates with state programs and teams
• Maintains case records in compliance with regulations, standards, and protocols
• Maintains knowledge of current OCES policies and standards, and funding source regulations
• Other duties as assigned

What You Will Bring

• Bachelor's degree in nursing, social work, human services, or related field
• Current Social Work License preferred
• Must possess knowledge of long-term care, case management, discharge planning, community resources, programs, and benefits to help support an individual's transition from an institutional to a community setting
• Two years of experience in the social services field including a minimum of one year of experience with transition support activities
• Excellent verbal and written communication skills
• Excellent interpersonal and conflict resolution skills
• Excellent organizational skills and attention to detail
• Strong analytical and problem-solving skills
• Strong supervisory and leadership skills
• Proficient with Microsoft Office Suite or related software

What You Will Get

• Ability to work with an enthusiastic team of like-minded individuals
• Opportunity to develop professionally in your chosen career
• Great work/life balance: 35-hour work week with some flexibility; no weekends
• Exceptional benefits: generous paid time off policies; company paid LTD and life insurances; 401K plan