Community Transition Navigator

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

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