Hybrid Community Transition Care Manager

Agency on Aging of South Central CT; North Haven (CT); Hybrid; USD 47,000 - 63,000; Full time

Benefits offered by this job

Hybrid work schedule

15 days PTO during first year

12 paid holidays annually

Medical, dental, and vision insurance

403(b) retirement plan with 3.5% match

Mileage reimbursement

Professional development and training

Supportive, collaborative work env.

Meaningful work

Job summary

Agency on Aging of South Central Connecticut (AOASCC) is hiring a Specialized Care Manager to join the Money Follows the Person program in North Haven. You will coordinate transitions from institutional care to community living, develop person-centered care plans, and provide ongoing support to ensure safe, independent living.

The role emphasizes assessments, service coordination, advocacy, and post-transition follow-up, with a hybrid schedule after orientation.

Qualifications

• Bachelor's degree in Social Work, Human Services, Nursing, Psychology, Gerontology, Public Health, or a related field.
• Minimum of two years of experience in case management, care management, social services, discharge planning, healthcare, or long‑term services and supports.
• Strong assessment, documentation, organizational, and problem‑solving skills.
• Excellent communication and interpersonal skills.
• Ability to work independently and collaboratively within a multidisciplinary team.
• Valid driver's license and reliable transportation for community visits.

Responsibilities

• Establish timely contact with assigned consumers and their authorized representatives.
• Conduct comprehensive assessments to identify medical, functional, social, and environmental needs.
• Gather and maintain required documentation, including informed consent forms, assessments, and supporting records.
• Identify barriers to community transition and develop strategies to address them.
• Develop individualized, person-centered care plans that support successful community living.
• Coordinate services and supports with healthcare providers, community agencies, family members, and interdisciplinary team members.
• Monitor service delivery and make recommendations to ensure participant needs are met.
• Collaborate with housing coordinators, transition coordinators, facility staff, and state partners throughout the transition process.
• Participate in discharge planning and transition meetings.
• Coordinate community-based services, supports, and authorizations necessary for discharge.
• Ensure emergency backup plans and required documentation are completed prior to transition.
• Support participants and families through all phases of the transition process.
• Provide post-transition follow-up and quality management services.
• Maintain regular contact with participants according to program requirements.
• Monitor participant stability, address concerns, and facilitate access to additional resources as needed.

Skills

Communication

Organizational skills

Problem solving

Independent & collaborative work

Education

Bachelor's degree in Social Work, Human Services, Nursing, Psychology, Gerontology, Public Health, or related field

Job description

Agency on Aging of South Central Connecticut (AOASCC) is hiring a Specialized Care Manager to join the Money Follows the Person program in North Haven. You will coordinate transitions from institutional care to community living, develop person-centered care plans, and provide ongoing support to ensure safe, independent living.

The role emphasizes assessments, service coordination, advocacy, and post-transition follow-up, with a hybrid schedule after orientation.