What are the responsibilities and job description for the Nursing Home Transition Coordinator- Lehigh/Northampton position at United Disabilities Services?
The Nursing Home Transition Coordinator (NHTC) assists eligible individuals in nursing facilities to transition safely into home- and community-based settings. The NHTC collaborates with residents, families, case managers, service coordinators and community resources to develop and implement person-centered transition plans that promote long-term independence and quality of life. The coordinator ensures transitions comply with Pennsylvania DHS Office of Long-Term Living (OLTL) regulations and the individual’s Managed Care Organization (MCO) requirements, while advocating for residents to exercise choice and achieve their desired quality of life.
Key Responsibilities
- Community Resource Linkage
- Transition Planning
- Pre-Transition Assessment
- Day-of-Transition Support
- Post Transition Follow-up
Job Requirements:
Bachelor’s degree in social work, Sociology, Psychology, Gerontology, Human Services, or a related behavioral science field OR at least3 years of professional experience in a social service, healthcare, or long-term care setting.
- Comprehensive knowledge of Pennsylvania’s long-term services and supports system, Medicaid waivers, nursing home regulations, and community-based resources is a plus.
- Problem Solving. - The main problem-solving skills for a Nursing Home Transition Coordinator are finding solutions to barriers that prevent a resident from moving home. This involves being a Creative Resource Finder to locate affordable housing and necessary help, acting as a System Navigator to quickly approve services and payments through state programs (like waivers), and being a Quick Trouble Shooter to handle sudden problems like a delayed discharge or a crisis right after the move. Ultimately, the coordinator must be an excellent Mediator and Planner to get everyone—the resident, family, nursing home, and new providers—on the same page for a safe transition.