Care Transitions Specialist

Prince William County Government•Prince William County, VA

About The Position

The Part-Time Care Transitions Health Coach helps residents navigate the transition from hospital to home. The coach supports patients and caregivers during recovery by providing education and personalized assistance to promote health, independence, and self-advocacy. The role involves telephonic hospital outreach, post-discharge home visits, and follow-up phone calls. The coach helps patients understand medications, navigate follow-up appointments, recognize warning signs or symptoms, and develop self-management strategies. The position emphasizes patient-centered care and collaboration with healthcare providers to support successful recovery and quality of life.

Requirements

High school diploma or G.E.D.
Four years of experience with older adults who have complex care needs within the hospital system, case management, and service coordination.
Experience entering, maintaining, and retrieving client information in electronic database systems.
Valid driver's license.
Must pass a criminal background check pursuant to VA Code Ann. 19-392-92 (2010) and the Older Americans Act of 1965 as amended in Section 701.
Must pass a DMV record check.
Must complete a physical and TB screening and be cleared for employment.
Must complete CPR/First Aid/AED and mandated contracted systems training.
Must attend required agency trainings and events.
Mandated reporter of elder abuse.

Nice To Haves

Bachelor's degree or higher in Behavioral Sciences, Human Services, Social Work, Gerontology, Education, Communications, Public Administration, or a related field.
Five years of experience working with older adults with disabilities.
Thorough knowledge of community resources and programs, including health information privacy and benefited programs.
Ability to manage multiple priorities and meet required deadlines and time-sensitive schedules.
Experience researching and identifying community resources for clients, particularly resources related to older adults and caregivers.
Experience building trust with clients to gather sensitive or complex information.
Bilingual English/Spanish speaker.

Responsibilities

Conduct telephonic hospital outreach, post-discharge home visits, and follow-up phone calls with patients.
Educate and support patients in understanding their medications and navigating follow-up care appointments.
Help patients recognize warning signs or symptoms and develop self-management strategies.
Support patients and caregivers in navigating the transition from hospital to home and encourage self-advocacy.
Enter, maintain, and retrieve client information in electronic database systems.