Community Transition Liaison

Old Colony Elder Services (OCES); Brockton (MA); On-site; USD 36,000 - 39,000; Full time

Benefits offered by this job

Paid time off

Long-term disability

Life insurance

401K plan

Job summary

Old Colony Elder Services (OCES) is expanding services to support seniors transitioning from nursing facilities to the community across the south shore region. As a Community Transition Liaison, you will serve as the onsite contact for residents, families, and NF staff, conduct visits, and guide discharge planning and referrals to community resources.

OCES offers a 35-hour work week with flexible options, generous benefits including PTO, LTD, life insurance, and a 401K plan, with a competitive

Qualifications

• Bachelor's degree in nursing, social work, human services, or related field.
• Current Social Work License preferred.
• Knowledge of long-term care, case management, discharge planning, community resources, programs, and benefits for transition.
• Two years in social services with at least one year in transition support.
• Excellent verbal and written communication; interpersonal and conflict resolution; organizational and detail orientation; analytical and leadership abilities.

Responsibilities

• Acts as onsite point of contact for residents, families, HCP and NF staff.
• Visits with residents to increase awareness of services and transition to the community.
• Participates in conversations to inform options and transition planning.
• Completes screening to determine referrals to HCBS Waivers and programs for transition.
• Facilitates person-centered planning and needs assessment.
• Gathers housing documents and identifications.
• Completes referrals to other programs and follows up for timely transition.
• Participates in IDP meetings and coordinates with consumer, family and agencies.
• Leads discharge planning meetings with consumer, family, NF staff and agencies.
• Coordinates with state programs and teams.
• Maintains case records in compliance with regulations.
• Keeps knowledge of OCES policies and funding source regulations.
• Other duties as assigned.

Skills

Communication skills

Interpersonal skills

Organizational skills

Analytical skills

Leadership

Microsoft Office

Education

Bachelor's degree in nursing, social work, human services, or related field

Job description

OCES is growing!

We are expanding to 11 more towns covering the south shore area, including Quincy, Braintree, Weymouth, etc.

OCES supports older adults and individuals with disabilities by providing vital information and coordination of services. By promoting healthy, safe living for our consumers, we hope to allow them to stay active and engaged in their lives and in their own communities for as long as possible.

Our mission: Through the talents of an experienced and diverse workforce, OCES supports the independence and dignity of older adults and individuals with disabilities by providing essential information and services that promote healthy, safe living which positively impacts our community.

We are seeking a Community Transition Liaison to facilitate successful discharge activities and other support activities for assigned consumers focusing on the transition from nursing facilities (NF) to community. The Community Transition Liaison is responsible for facilitating successful discharge activities and other support activities for assigned consumers focusing on the transition from nursing facilities (NF) to community.

What You Will Do

• Acts as onsite point of contact for residents, families, health care proxy (HCP) and NF staff
• Visits with residents to increase awareness of service and introduce transition to the community
• Participates in resident, family and/or HCP conversations to inform options and transition planning
• Completes the directional screening tool to determine potential appropriateness for referrals to HCBS Waivers and other programs to support the transition to the community and meet the consumer's needs once in the community setting
• Facilitates person-centered planning and needs assessment
• Begins the process of gathering necessary documentation and identification needed for housing

Applications And Other Public Benefits

• Completes referrals to other programs and follows-up on referrals to ensure timely transition
• Participates in Interdisciplinary Discharge Planning (IDP) meetings and facilitates communication among the consumer, family members and community agencies.
• Participates and facilitates in discharge planning meetings with the consumer, family, nursing facility staff and other agencies that will support the consumer in the community upon discharge
• Coordinates with state programs and teams
• Maintaining case records in compliance with regulations, standards, and protocols
• Maintaining knowledge of current OCES policies and standards, and funding source regulations
• Other duties as assigned.

What You Will Bring

• Bachelor's degree in nursing, social work, human services, or related field
• Current Social Work License preferred
• Must possess 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.
• Excellent interpersonal and conflict resolution skills.
• Excellent 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

What You Will 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; no weekends
• Exceptional benefits: generous paid time off policies; company paid LTD and life insurances; 401K plan.

Salary: $26.80 per hour

OCES is an open, welcoming organization that respects our diversity. We encourage all qualified people to apply!