Community Transition Navigator

Old Colony Elder Services, Inc.; Brockton (MA); On-site; USD 60,000 - 80,000; Full time

Benefits offered by this job

Develop professionally

Great work-life balance

Exceptional benefits

401K plan

Job summary

Old Colony Elder Services, Inc. seeks a Community Transition Liaison to support residents transitioning from nursing facilities to community settings on the South Shore.

You will coordinate discharge activities, conduct screenings, facilitate care planning, gather housing documentation, and collaborate with families, NF staff, and community agencies to ensure timely transitions. The role requires on-site presence, strong communication, and organizational skills; a Bachelor’s degree in a related

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 to support transitions.
• Two years in social services with at least one year of transition experience.
• Excellent verbal and written communication and interpersonal skills.
• Strong organizational and problem-solving abilities.
• Supervisory and leadership experience.
• Proficient with Microsoft Office Suite.

Responsibilities

• Acts as onsite point of contact for residents, families, health care proxy (HCP) and NF staff during transitions from NF to community.
• Visits residents to raise awareness of services and transition options.
• Participates in conversations to inform options and transition planning.
• Completes the directional screening tool to determine referrals for HCBS Waivers and other programs.
• Facilitates person-centered planning and needs assessment.
• Begins gathering documentation for housing applications and public benefits.
• Completes referrals to other programs and follows up for timely transition.
• Participates in IDP meetings and coordinates among consumer, family, and agencies.
• Coordinates with state programs and teams.
• Maintains case records per regulations and protocols.
• Keeps knowledge of OCES policies and funding regulations updated.
• Other duties as assigned.

Skills

Verbal communication

Written communication

Interpersonal skills

Organizational skills

Analytical thinking

Leadership

Conflict resolution

Microsoft Office

Education

Bachelor's degree

Social Work license (preferred)

Tools

Microsoft Office Suite

Job description

Old Colony Elder Services, Inc. seeks a Community Transition Liaison to support residents transitioning from nursing facilities to community settings on the South Shore.

You will coordinate discharge activities, conduct screenings, facilitate care planning, gather housing documentation, and collaborate with families, NF staff, and community agencies to ensure timely transitions. The role requires on-site presence, strong communication, and organizational skills; a Bachelor’s degree in a related