Transitional Care Coordinator

San Francisco Campus for Jewish Living•San Francisco, CA

1d•$28 - $35•Onsite

About The Position

As a Transitional Care Coordinator (TCC), you will provide psychosocial support to patients and their families, facilitate discharge planning, meet documentation requirements, and function as a member of the interdisciplinary care team at the Jewish Home & Rehab Center. This role supports the planning, organization, implementation, and evaluation of Social Services operations in accordance with federal, state, and local regulations, as well as the facility’s established policies and procedures.

Requirements

Bachelor’s degree in Social Work or a related human services field, including but not limited to sociology, gerontology, rehabilitation counseling, or psychology.
Minimum of one (1) year of supervised social work experience in a healthcare setting working directly with individuals.
Minimum of one (1) year of experience with case management and discharge planning.
Strong interpersonal skills and ability to work collaboratively as part of an interdisciplinary team.
Ability to communicate effectively with patients, families, and staff at all levels of the organization.
Effective time management skills with the ability to organize and prioritize workload.
Understanding of Medicare and Medi-Cal guidelines.
Ability to lift, push, or pull a minimum of fifteen (15) pounds.
Ability to exert muscle force to lift, push, pull, or carry objects.
Ability to use abdominal and lower back muscles over time without fatigue.
Ability to stand and/or sit for extended periods.
Ability to bend, stoop, stretch, twist, sit, and reach.
Fine motor skills and good visual and auditory acuity.
Ability to maintain composure in stressful situations and work effectively under pressure.
Ability to interact tactfully with residents, families, staff, visitors, government agencies, and the public.
Ability to make independent decisions when circumstances require.
Ability to relay important information concerning a resident’s condition to appropriate staff.
Ability to maintain a positive attitude and contribute to a collaborative team environment.

Nice To Haves

Knowledge of medical terminology preferred.

Responsibilities

Coordinate with the interdisciplinary team and other departments in the provision of social services and discharge planning.
Complete comprehensive psychosocial assessments of patients within the appropriate timeframe.
Act as a liaison between patients, their families, internal departments, and community referral partners throughout the patient’s stay in Short-Term Rehabilitation and Long-Term Care.
Assist patients and families in accessing concrete services and resources.
Demonstrate knowledge of and ability to utilize community resources effectively.
Respond to crisis situations involving patients, families, and staff with guidance from supervisors.
Facilitate individual counseling for patients and families as needed.
Participate in the development of patient care plans and establish appropriate goals and treatment interventions for social services.
Encourage residents and responsible parties to participate in care planning and attend care plan meetings.
Maintain accurate and timely documentation in compliance with federal and state regulations and Jewish Home policies, including but not limited to Initial Assessments, Psychosocial/Mental Status Assessments, Care Plans, Social Service Progress Notes, and Discharge Planning documentation.
Maintain confidentiality of all patient and facility information.
Serve as a patient advocate and ensure patients are informed of their rights, responsibilities, and insurance benefits, as well as any changes that may affect them.
Perform other duties as assigned by the Director of Social Services.