What are the responsibilities and job description for the Transitions Coach/ Social Worker position at Old Colony Elder Services (OCES)?
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! What you\'ll do: 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 What you\'ll
bring: 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. What you\'ll get: Ability
to work with an enthusiastic team of like-minded individuals Opportunity
to develop professionally in your chosen career Great work/life balance:
35-hour work week with some flexibility. Hybrid work environment (home
with some in-office requirements) Exceptional benefits: health benefits
available on day 1; generous paid time off policies; company paid LTD
and life insurances, 401K plan
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! What you\'ll do: 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 What you\'ll
bring: 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. What you\'ll get: Ability
to work with an enthusiastic team of like-minded individuals Opportunity
to develop professionally in your chosen career Great work/life balance:
35-hour work week with some flexibility. Hybrid work environment (home
with some in-office requirements) Exceptional benefits: health benefits
available on day 1; generous paid time off policies; company paid LTD
and life insurances, 401K plan