Care Transitions Specialist

Shift Schedule: Monday-Friday 9AM-5PM

Hours Per Week: 35

• Identify home-based issues that may be linked to readmission risk
• Provide direct services and referrals to support stable home based functioning, focusing on:
  • Medication/DME (other supplies): Ensure patient has medication, supplies and equipment and understands prescribed use
  • Patient Education: Ensure patient is aware of their health conditions and how to manage them, and understands red flags and health risks
  • Health Care Provider Communication and Coordination: Ensure patient has a primary care provider (PCP), update PCP on patient status, assist patients with follow up appointments
• Screen for and identify social and mental health needs of patients and provide closed-loop referrals

• 
  The provision of in-hospital (or other clinical setting and, in-home assessments of the social and emotional needs of the older adult client and their family, utilizing prescribed standardized assessment instruments;
• The provision of a full range of social services for the older adult client(s) and family, including:
  • Education and support to improve disease self-management and prevent avoidable hospital use
  • Screening of client eligibility, application for, and advocacy in securing benefits and entitlements
  • The arrangement for direct provision of services such as transportation, homecare services, meals on wheels/nutrition services, public assistance, Medicare, Medicaid, emergency cash relief, legal aid, protective services, medical and psychiatric examination and therapy, housing, etc.
  • Referral, development of relationships and cooperative work with other community agencies, to meet the needs of clients
• Informing supervisors of situations of crisis or circumstances where the worker requires further guidance.
• Participating in training and team meetings.
• Collecting and inputting patient data into JASA’s Electronic Health Record system and assisting with analytics, reports and statistics, utilizing computers.
• Performs such other duties as assigned.

• 
  International Medical Graduate or equivalent.
• Graduate of an Accredited College or University with B.A./B.S. degree
• Good writing/record keeping skills.
• Ability to read, write, speak, understand English.
• Ability to read, write, speak, understand Spanish (preferred).
• Must be computer literate, including ability to learn and use program-specific software.
• Ability to travel to clients' homes using mass transit, however, driving may be required for certain home visits.
• Able to negotiate any steps and barriers in clients' residences.
• Hospital discharge planning or other health care experience preferred.
• Understanding and appreciation of the roles of race, religion, ethnicity, sexual preference, and individual values as they relate to serving clients and families.