Transitions Coach

Old Colony Elder Services•Brockton, MA

5d•Hybrid

About The Position

OCES supports elders and individuals with disabilities by providing information and coordination of services to promote healthy, safe lives and help consumers remain active and engaged in their communities. The Transitions Coach provides transitional coaching to eligible patients and consumers to reduce the likelihood of admission or readmission and support a smooth transition from hospital to home. The role works with consumers during discharge planning and after discharge, coordinating referrals and services and maintaining compliant case records. The position has a 35-hour work week with some flexibility and a hybrid work environment, with work from home and some in-office requirements.

Requirements

Knowledge of long-term care, case management, discharge planning, community resources, programs, and benefits that support transitions from an institutional to a community setting.
Two years of experience in the social services field, including at least 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.
Proficiency with Microsoft Office Suite or related software.
Ability to travel and reliable means of transportation.
Personal computer with secure internet access at home.

Nice To Haves

Bachelor's degree in nursing, social work, human services, or a related field is highly preferred.

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 homes following hospital discharge and follow up with them for 30 days post-discharge.
Carry a rotating caseload of 24 consumers.
Work closely with the Blue Cross Blue Shield (BCBS) RN Care Management team.
Make referrals to BCBS programs, including care management, dietician, behavioral health, Alzheimer's, and member services.
Attend training on understanding and using the Eric Coleman Transitions Model.
Help consumers identify community needs and make appropriate referrals to additional HCBS services.
Participate in a monthly virtual coach meeting with other Transitions Coaches throughout the state.
Maintain case records in compliance with regulations, standards, and protocols.
Maintain knowledge of current OCES policies and standards and funding-source regulations.