Transitions Coach

Old Colony Elder Services • Brockton, MA

1d • Hybrid

About The Position

OCES supports elders and individuals with disabilities by providing information and coordination of services that promote healthy, safe lives and help consumers remain active and engaged in their lives and communities. The Transitions Coach provides transitional coaching to eligible patients and consumers to reduce the likelihood of hospital admission or readmission and support a smooth transition from hospital to home. The role includes working with consumers for 30 days after discharge, coordinating with clinical and community partners, and maintaining compliant case records.

Requirements

• Bachelor's degree in nursing, social work, human services, or a related field is highly preferred.
• Knowledge of long-term care, case management, discharge planning, community resources, programs, and benefits that support transitions from institutional to community settings.
• 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.

Responsibilities

• Participate in hospital-led discharge planning meetings.
• Work with consumers to understand their discharge plans after a hospital stay.
• Meet with consumers at home 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.

Benefits

• Generous paid time off policies.
• Company-paid long-term disability insurance.
• Company-paid life insurance.
• 401(k) plan.
• Opportunity to develop professionally.
• 35-hour work week with some flexibility.
• Hybrid work environment with work from home and some in-office requirements.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed