Community Transition Liaison

Minuteman Senior Services•Burlington, MA

13d•$26 - $26•Remote

About The Position

Under the supervision and guidance of the Community Transitions Supervisor, the Community Transition Liaison supports nursing facility residents aged 22 and older who are considering a transition to a community setting. The program serves both short-stay admissions and long-term residents, including people with criminal justice system involvement, behavioral health needs, specific diagnoses, housing insecurity, or needs for specialized referrals to state programs and other agencies. The role helps residents explore community supports, assess eligibility, plan transitions, gather documentation for housing and public benefits, and connect with appropriate programs. The liaison works with residents, families, nursing facility staff, and other agencies to coordinate discharge planning and community supports. This is a remote position involving visits to nursing facilities, occasional office meetings, and travel by car for home visits or other meetings. The position is 35 hours per week. The stated annual salary is $47,320, equivalent to the posted rate of $26.00 per hour. The role has access to protected health information (PHI) and personally identifiable information (PII), and requires compliance with the employer’s confidentiality policy, HIPAA regulations, and Massachusetts Executive Order 504.

Requirements

Sensitivity and willingness to work with individuals with complex health needs.
Strong interviewing and assessment skills.
Ability to listen and create person-centered plans.
Strong written and oral communication skills.
Ability to manage time and competing priorities in a fast-paced environment.
Strong computer skills, including accurate and fast data entry, electronic health record management, and Microsoft Suite programs.
Ability to work well with people of diverse backgrounds, incomes, ages, races, and abilities, including people with mental health, physical, cognitive, or sensory needs.
Knowledge of long-term care, case management, discharge planning, community resources, programs, and benefits that support transitions from an institution to a community setting.
Reliable transportation and a valid driver’s license in good standing.
Ability to work independently as a self-starter, manage interruptions, solve problems, maintain professional boundaries, and handle multiple priorities.

Nice To Haves

Familiarity with relevant health and human service programs and agencies, or willingness to learn about them.

Responsibilities

Visit nursing facility residents to increase awareness of community supports and services and introduce transition as a potential option.
Participate in conversations with residents and families to discuss options and inform transition plans.
Conduct assessments to determine eligibility and help plan transitions to the community.
Begin gathering the documentation and identification needed for housing and public-benefit applications.
Complete referrals to other programs and follow up to support timely transitions.
Identify individuals appropriate for the Community Transition Liaison Program based on their desire to transition to community living, including use of the PASRR portal to facilitate resident identification.
Participate in and facilitate discharge-planning meetings with consumers, families, nursing facility staff, and agencies that will support consumers after discharge.
Liaise with nursing and other professionals at skilled nursing facilities.
Coordinate with state programs and teams.
Attend required meetings and complete required trainings.
Perform other duties as assigned.
Adhere to the employer’s confidentiality policy, HIPAA regulations, and Massachusetts Executive Order 504 when accessing PHI and PII.