Transitions Coach/ Social Worker

What You'll Do

• Participate in hospital led discharge planning meetings
• Work with consumers to understand their discharge plans after a hospital stay
• Meet with consumers in their home following a hospital discharge and follow up with consumers for 30 days post-discharge from the hospital
• Carry a rotating caseload of 24 consumers
• Work closely with Blue Cross Blue Shield (BCBS) RN Care Management team
• Make referrals to BCBS program such as care management, dietician, behavioral health, Alzheimer's, member services
• Attend training specific to understanding and using the Eric Coleman Transitions Model
• Aid consumers in identifying needs in the community and make appropriate referrals to additional HCBS services
• Engage in a monthly virtual coach meeting with other Transitions Coaches throughout the state
• Maintain case records in compliance with regulations, standards, and protocols
• Maintain knowledge of current OCES policies and standards, and funding source regulations

What You'll Bring

• Bachelor's degree in nursing, social work, human services, or related field highly preferred
• 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
• Interpersonal and conflict resolution skills
• 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
• Ability to travel and reliable means of transportation
• Must have a personal computer with secure internet access at home