SUMMARY: The Transition of Care Specialist is responsible to assist in a safe and effective discharge of members from the hospital setting to the community. The Specialist serves as a bridge between professional staff in the care setting (i.e. hospital, physician, social worker and nurse). The Transition of Care Specialist provides information and guidance and care coordination for effective care transition from hospital to community. DUTIES AND RESPONSIBITIES: Conducts telephonic assessment of members status and discharge plans with hospital(s).Evaluates discharge plan and appropriateness of discharge status, in coordination with CM department.Serves as a guide to the hospital discharge planner to promote better understanding of healthcare issues and ongoing care needs the member may have.Evaluates/reviews discharge summary/homecare needs and support systems to formulate a plan that will lead to, appropriate referral(s) to community or other programs (i.e. Hospice, Palliative care, home care services) as appropriate.Engages with Care management team as needed to collaboratively work on members discharge needs (if applicable).Completes required documentation in a timely manner.Other duties as assigned.QUALIFICATIONS:BSW degree preferredSome knowledge of Case Management in a health care setting, experience in a MLTC, Managed Care, Home Care or Community Health Setting preferredExcellent interpersonal, verbal and written skills.Able to communicate effectively on the telephone.PHYSICAL REQUIREMENTS: The physical demands described here represent those that must be met to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit and talk or hear. The employee frequently is required to stand; walk; and use hands to finger, handle, or feel objects, tools, or controls. The employee is occasionally required to reach with hands and arms. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job involve normal vision.