Transitions Coach/Social Worker

Old Colony Elder Services•Brockton, MA

10h•Hybrid

About The Position

OCES supports elders and individuals with disabilities by providing information and coordination of services promoting healthy, safe lives for our consumers. We want to help them stay as active and engaged in their lives and in their own communities. OCES is looking for a Transitions Coach, responsible for providing transitional coaching to eligible patients/consumers to create a smooth transition from hospital to home. Check out our web site (www.ocesma.org) to see what our Transitions Department and other OCES programs are doing to support the needs of our consumer base!

Requirements

Bachelor's degree in nursing, social work, human services, or related field highly preferred
Knowledge of long-term care, case management, discharge planning, community resources, programs, and benefits to help support an individual's transition from an institutional to a community setting.
Two years of experience in the social services field including a minimum of one year of experience with transition support activities.
Excellent verbal and written communication skills.
Interpersonal and conflict resolution skills.
Organizational skills and attention to detail.
Strong analytical and problem-solving skills.
Strong supervisory and leadership skills.
Proficient with Microsoft Office Suite or related software.
Ability to travel and reliable means of transportation.
Must have a personal computer with secure internet access at home.

Responsibilities

Participate in hospital led discharge planning meetings
Work with consumers to understand their discharge plans after a hospital stay
Meet with consumers in their home following a hospital discharge and follow up with consumers for 30 days post-discharge from the hospital
Carry a rotating caseload of 24 consumers
Work closely with Blue Cross Blue Shield (BCBS) RN Care Management team
Make referrals to BCBS program such as care management, dietician, behavioral health, Alzheimer's, member services
Attend training specific to understanding and using the Eric Coleman Transitions Model
Assist consumer's in identifying needs in the community and make appropriate referrals to additional HCBS services
Engage in a monthly virtual coach meeting with other Transitions Coaches throughout the state
Maintaining case records in compliance with regulations, standards, and protocols
Maintaining knowledge of current OCES policies and standards, and funding source regulations