Job Description:

We look for skilled employees who are passionate about our mission and values, and providing excellent customer service.

We value our employees and the people we serve and it shows!

Our mission is to promote dignity, independence and health: honor choice & empower people.

Our Values are Service, Compassion, Integrity, Professionalism

Recruitment #:  410-07-23

Closes: Open Until Filled

Location: Salem, OR

Salary Range: $4,566 per month, with excellent benefits (see below),

Excellent Benefits: Medical/Dental 100% paid for employee and 90-98% for dependents, generous Paid-time off, Public Employee Retirement (PERS), Employee Assistance Plan, Long Term Disability, great culture.

General Description

Performs Professional-level work in the provision of social services by helping consumers and/or families to prevent unnecessary placement in nursing facilities and facilitate transitions for those who can be better served in a lower level of care, such as in-home or a community-based setting.

Essential Functions

1. Determine the need and appropriateness of Diversion and Transition Services
2. Develop transition plan
3. Implement, monitor and adjust transition plan
4. Transition case to ongoing Case Manager
5. Support and promote Diversion and Transition services
6. Promote Agency services and Aging and Disability Resources Connection (ADRC) concept
7. Facilitate confidence in Diversion and Transition Case Manager, and therefore the Agency and programs
8. Protect consumers and reduce Agency risk
9. Provide excellent customer service in a professional manner

1. Determine the need and appropriateness of Diversion and Transition Services

• Conduct consumer assessments to identify need and determine eligibility for services
• Carry Nursing Facility caseload to better transition consumers to lower level of care as appropriate
• Work directly with hospitals on new referrals for long term care services eligibility and placement
• Gather information through interviews, observations, other staff, hospital discharge planners, and other resources 
• Consider consumer’s preferences, goals, safety, resources, etc. in determining Assessments and placements
• Complete assessment tool
• Assist consumers in Long Term Care Facilities which are closing and no longer operate under Medicaid to find alternate care
• Carry enhanced care facility cases and manage the complexities of them
• Carry specific need contract cases and manage the complexities of them

2. Develop transition plan

• Analyze information gathered during assessment.
• Determine the type of services necessary and the best type of in-home or community-based setting
• Work with the consumer and/or family to accept plan developed

3. Implement, monitor, and adjust transition plan

• Coordinate the delivery of services identified
• Arrange care setting, medical supplies, equipment, transportation, etc.
• Provide assistance to alleviate serious environmental, medical, or social problems
• Work with other partners to assist in effective transition
• Evaluate the meeting of consumer needs through required monitoring for 30-90 days on case transfers and specialized contracts placements. This will include monitoring by phone, and in-person contact.
• Evaluate delivery and quality of services
• Facilitate provider payment
• Adjust plan according to changing care needs of consumer, handling issues as they arise
• Track work in Diversion and Transition database

4. Transition case to ongoing Case Manager

• Determine success and stability of transition plan
• Identify the appropriate receiving Case Manager
• Provide case management information through case notes/files
• Communicate with all individuals involved to ensure a smooth transition

5. Support and promote Diversion and Transition services

• Communicate with appropriate staff and partners
• Provide education and outreach on Diversion and Transition services for Agency staff, community partners, and the public

6. Promote Agency services and ADRC concept

• Educate self of Agency programs and services and other resources available for populations served, including using ADRC of Oregon online resource directory
• Understand current issues and solutions for seniors and people with disabilities
• Establish cooperative relationships with other human service agencies and organizations

7. Facilitate confidence in Diversion and Transition Case Manager, and therefore the Agency and programs

• Embrace and exhibit the Agency Mission, Vision, and Core Values
• Use a person-centered approach
• Provide excellent customer service
• Meet the needs of consumers
• Follow through and meeting deadlines
• Interact with others in a respectful and culturally appropriate way
• Work effectively with a wide variety of individuals
• Maintain skills and knowledge to perform duties
• Provide suggestions for improvement

8. Protect consumers and reduce Agency risk

• Follow policies, regulations and requirements of project and Agency; document plan and progress as required.
• Provide documentation as set forth by Federal, State, funding regulations, and Agency policy 
• Serve as a Mandatory Reporter of suspected abuse of vulnerable populations as required by policy and regulation
• Maintain and sharing information according to privacy regulations

9. Provide excellent service in a professional manner

• Apply the required knowledge and skills and exhibit critical thinking and problem solving
• Exhibit good decision making, problem solving and work habits
• Meet quality standards in accuracy, judgment, timeliness and following policy and procedure
• Exhibit good work habits, including organizational skills, regular attendance, working independently, seeking and offering assistance when needed
• Follow policies and procedures
• Work independently, but seek and offer assistance when needed
• Exhibit technology skills related to the work needing to be done, (word processing, spreadsheets, database, internet research, mail, IM, phones, copiers, assessment programs like as CAPS, Oregon ACCESS, etc.)
• Exhibit a positive attitude towards consumers, co-workers and others

Job-specific skills and knowledge

• Experience working with seniors and people with disabilities and the issues experienced by these populations (social, physical, care, etc.)
• Knowledge of transition techniques, services, resources available, and service eligibility requirements
• Knowledge of the Case Manager position, processes and responsibilities
• Ability to interview others, observe, and assess situations accurately
• Knowledge of family dynamics
• Ability to translate observations and assessments to care plan
• Knowledge of long term care settings and appropriateness for consumer needs
• Knowledge of federal and state laws and regulations regarding long term care placements
• Knowledge of components of services, supplies, equipment, and transportation to ensure services are appropriate to meet needs and delivered effectively
• Ability to respond to issues and problem solve solutions
• Knowledge of and experience with case management and case management assessment tools
• Ability to learn specific tools used by Agency
• Ability to explain services and concepts in easily understood terms
• Ability to develop community relationships
• Ability to identify outreach opportunities
• Presentation skills and experience
• Understanding of ADRC
• Ability to source information regarding available services
• Ability to build relationships and network
• Ability to be a self-starter and be adaptable to change
• Ability to be a team-player
• Ability to set goals based on Agency expectations and develop a plan to meet and/or exceed goal expectations
• Continuous learning about issues and solutions for populations served
• Ability to learn and apply policies, regulations, requirements, rules around mandatory reporting, privacy, and confidentiality
• Knowledge of Family Caregiver Support Program, and general knowledge of the dynamics of care giving and resources available

General Skills Needed to Meet Agency Expectations

Must be able and willing to perform the following:

• Support the agency mission and exemplify its core values—integrity, professionalism, service, and compassion
• Serve as a mandatory reporter of suspected cases of neglect, exploitation, and abuse of vulnerable populations as required by policy and regulation, and make the appropriate referral to a responsible agency such as Child or Adult Protective Services Units
• Interact and work effectively with others in a team to deliver services to consumers
• Demonstrate good interpersonal communication skills through written, verbal, and nonverbal communication
• Use sound organizational skills to meet deadlines in a timely, accurate, and efficient manner
• Speak, read, write, and understand English and follow verbal and written instruction
• Perform other work as assigned by the supervisor