Care Transitions Coordinator

Mystic Valley Elder Services•Malden, MA

1d•$60,000 - $65,000•Hybrid

About The Position

The Care Transitions Coordinator is responsible for ensuring smooth and effective transitions of care for consumers moving between healthcare settings (e.g., hospital to home, or community-based care). This role focuses on reducing readmissions, improving consumer outcomes, and enhancing the continuity of care by coordinating services, educating consumers and families, and collaborating with healthcare and community providers.

Requirements

Bachelor's degree in social work, human services or related field or associate's degree with 5 or greater years relevant work experience can be submitted for portion of degree.
Required proof of immunizations: negative TB test (has been done within 1 year), MMR (measles, mumps, rubella), Chicken Pox; OR consent to have titer drawn for above immunizations. Annual flu shot, Covid-19 vaccine.
Ability to be a self-starter, work independently, and demonstrate flexibility in responding to consumer needs.
Ability to be flexible and be able to adapt to, and work effectively in, the culture of a medical environment.
Excellent interpersonal skills with demonstrated ability to communicate across all levels, including staff, family and external partners.
Ability to maintain confidentiality while working with sensitive information or in sensitive situations.
Highly resourceful team player, with the ability to work effectively independently or as a team.
Demonstrates a willingness to take on new tasks with a general attitude that no task is too small, impossible, or cannot be improved.
Expertise in the following platforms: Microsoft Office 365 (Word, Outlook, Teams, Excel, and PowerPoint), Adobe Pro, Zoom and other web-based applications.
Private Transportation

Nice To Haves

Case management and experience with the older adult population preferred.
Two years of experience in individual needs assessment and care planning, with a focus on eldercare issues and resources, preferred.

Responsibilities

Serve as the primary point of contact for consumers and families during care transitions, ensuring seamless communication between hospitals, primary care providers, home health agencies, health care payors, and community resources.
Conduct post-discharge follow-up calls and home visits (as applicable) to assess consumer needs, reinforce discharge instructions, and ensure adherence to treatment and medication plans.
Identify potential barriers to care (e.g., transportation, financial, or social issues) and connect consumers with appropriate community resources and support services.
Documentation is timely and accurate, including consumer and service data in Aging & Disability (A&D) and other required electronic medical records (EMR).
Participate in interdisciplinary team meetings and care management.
Compile and submit required statistics and reports.
Participate in community education and outreach.
Assure consumers are connected to appropriate community programs and services that address social determinants of health.
Participate in required orientation and training including ASAP training, hospital orientation and EMR training.