Community Transition Navigator for Care Management

Tri Valley, Inc.; Dudley (MA); On-site; USD 42,000 - 66,000; Full time

Job summary

Tri Valley, Inc. is seeking a Community Transition Liaison to promote, educate, identify, and assist nursing home residents with options related to transitioning into the community.

You will meet with residents to raise awareness of supports and services, identify candidates for transition, and help gather documentation for housing and benefits to enable a smooth transfer. The role requires the ability to work with state programs, coordinate discharge steps, and serve as the onsite contact for

Qualifications

• Bachelor's degree preferred in Social Work or related field.
• Experience or strong interest in human services via previous work, internship, or study.
• Regular and reliable attendance; valid driver's license.

Responsibilities

• Meet with residents to increase awareness of community supports and services and introduce transition as a potential option.
• Identifies individuals appropriate for the program based on resident’s desire to transition to community living environment.
• Assist residents to determine the most appropriate supportive program and determine eligibility to ensure effective transition to the community.
• Assist with gathering all necessary documentation needed and completion of applications for housing and other public benefits.
• Manage the discharge process along with purchasing goods and services for transition.
• Have knowledge of and work closely with community partners of State programs to maximize resources and eligibility for services.
• Maintain regular communication with supervisor and nursing staff for expedited clinical screenings and care planning to support community planning and transition.
• Onsite point of contact for residents, families, skilled nursing facility (SNF) staff and all other parties involved with resident’s care for nursing facility transitions to the community.

Skills

Strong communication

Reliable transportation

Education

Bachelor’s degree in Social Work, Human Services or related field

Job description

Tri Valley, Inc. is seeking a Community Transition Liaison to promote, educate, identify, and assist nursing home residents with options related to transitioning into the community.

You will meet with residents to raise awareness of supports and services, identify candidates for transition, and help gather documentation for housing and benefits to enable a smooth transfer. The role requires the ability to work with state programs, coordinate discharge steps, and serve as the onsite contact for