Nursing Home Transition (NHT) Service Coordinator/Human Services
About The Position
The Nursing Home Transition (NHT) Coordinator plays a vital role in helping individuals safely and successfully transition from nursing facilities back to community-based living. This position works closely with participants, families, service coordinators, healthcare providers, and external agencies to ensure services and supports are in place before, during, and after discharge. The NHT Coordinator is responsible for adhering to all program requirements, maintaining timely and accurate documentation, and providing consistent participant support throughout the transition process.
Requirements
- Associate's or Bachelor's degree in Social Work, Human Services, Nursing, or a related field (Bachelor's degree strongly preferred).
- 1–2 years of experience in care coordination, case management, or related human services roles.
- Knowledge of Medicaid Waiver programs, Long-Term Services and Supports (LTSS), and Home and Community-Based Services (HCBS) strongly preferred.
- Experience working with individuals with disabilities or special needs.
- Strong skills in assessment, planning, and participant-centered service delivery.
- Excellent organizational, communication, and documentation skills.
- Ability to work effectively as part of an interdisciplinary team.
- Familiarity with community support systems, housing resources, health care, and human services.
- Must live in PA or be willing to travel to PA to complete home visits.
- PA State Police Background Check (e-PATCH)
- Child Abuse Clearance
- FBI Background Check
- MA Fraud Check
- Social Security Verification
- DMV Check
Responsibilities
- Serve as the primary point of contact for nursing home residents interested in community reintegration through the NHT program.
- Collaborate closely with Community-Based Service Coordinators (HCBS SCs) and other care team members.
- Coordinate comprehensive transition planning with participants, families, facility staff, housing providers, and community agencies.
- Secure housing and necessary community-based services prior to discharge.
- Track each participant's progress, ensuring appropriate services and supports are in place pre- and post-transition.
- Maintain accurate, up-to-date documentation in compliance with federal, state, MCO, and internal policies.
- Support agency outreach and marketing efforts.
- Identify and address quality assurance issues using both direct observation and data analysis.
- Provide field instruction and mentorship for peers, as appropriate.
- Perform additional duties as assigned by the supervisor.
- Travel within the assigned region; occasional overnight travel required for training and seminars.
Benefits
- Starting Hourly Rate: 21/hour, with the opportunity for performance-based increases.
- Flexible Schedule
- No on-call
- 15 Agency Paid Days Off (including 11 holidays)
- 18 PTO Days
- Paid Training Period
- Mileage Reimbursement
- Tuition Reimbursement
- Medical Insurance
- Company Paid Dental Insurance
- Company Paid Vision Insurance
- Company-paid life insurance with the option of adding additional for you and your family
- Up to 5% Match for 401(k)
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
Number of Employees
1-10 employees
