Transition Care Specialist

DC Government; Washington (District of Columbia); On-site; USD 62,000 - 86,000; Full time

Job summary

The District of Columbia Government's Department of Aging and Community Living (DACL) is seeking a Transition Care Specialist to help individuals prepare for and transition from a facility to the community.

Responsibilities include determining eligibility for Medicaid Elderly and Persons with Disabilities waiver services, providing case management for up to 30 days post-discharge, and coordinating with an interdisciplinary team to develop a Person-Centered Service Plan.

Qualifications

• 24 semester hours in behavioral or social sciences
• Combination of education and experience with 24 semester hours in behavioral or social sciences equating to a 4-year degree
• Specialized experience must have equipped the applicant with the knowledge, skills, and abilities for the position

Responsibilities

• Determine client eligibility for Medicaid Elderly and Disability (EPD) waiver services
• Provide case management in person and by telephone for up to 30 days post-discharge
• Develop a Plan of Care with the interdisciplinary team prior to transition
• Connect client to employment options and community resources and ensure home safety prior to discharge

Skills

Case management

Interdisciplinary collaboration

Information linkage

Education

24 semester hours in behavioral or social sciences

Combination of education and experience equating to a 4-year degree

Specialized experience relevant to duties

Job description

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The D.C. Department of Aging and Community Living (DACL) develops and carries out a comprehensive and coordinated system of health, education and social services for the District's older adults (60 years and older), people with disabilities (18 years and older), and their caregivers. The mission of the District of Columbia Department of Aging and Community Living is to advocate, plan, implement, and monitor programs in health, education, and social services for the elderly; to promote longevity, independence, dignity, and choice for aged District residents, District residents with disabilities regardless of age, and caregivers; to ensure the rights of older adults and their families, and prevent their abuse, neglect, and exploitation; to uphold the core values of service excellence, respect, compassion, integrity, and accountability; and to lead efforts to strengthen service delivery and capacity by engaging community stakeholders and partners to leverage resources.

The Transition Care Specialist position is part of the Nursing Home transition team and works with individuals to prepare for and transition from the facility to the community.

Duties and Responsibilities

The incumbent determines client eligibility for Medicaid Elderly and Person with Disabilities (EPD) waiver services, provides information and linkages to community services, and assists the Nursing Home Social Worker (NHSW) in planning a safe transition for the individual. Provides case management services in person and by telephone to clients for up to 30 days post-discharge (to be determined case by case).

Collaborates with the client and the interdisciplinary team to develop a Plan of Care to include in the comprehensive Person-Centered Service Plan prior to the transition. Connects the client to employment options and assists with locating community resources such as a physician, pharmacy, assisted living, adult day health program, durable medical equipment, etc., as needed and/or directed by the client, acts as a resource or consultant on community integration. Formulates and executes a plan, in collaboration with the client’s, to make the home safe prior to the client discharge date from a care facility.

Qualifications and Education

Degree:Successful completion of at least 24 semester hours of coursework in the behavioral or social sciences.

Or

Combination of education and experiencethat included at least 24 semester hours of course work in the behavioral or social sciences, and that provided applicants with knowledge of the behavioral or social sciences equivalent to a 4‑year degree as shown in A above.

Or

Specialized experience must have equipped the applicant with the particular knowledge, skills, and abilities to perform successfully the duties of the position to be filled.To be creditable, applicants must have one (1) year of specialized experience equivalent to at least the next lower grade level in the line of progression.

Licenses and Certifications

None

Work Conditions/Environment

The incumbent is located in a normal office setting. Visits to the field may include homes, offices, institutions, potential housing, meetings with providers, and work and training sites.

Other Significant Facts

Tour of Duty: Monday – Friday; 8:00 a.m. – 5:30 p.m.

Pay Plan, Series and Grade,CS-0101-12

Promotion Potential:No Known Promotion Potential.

Duration of Appointment: Career Service Permanent.

Collective Bargaining Unit (Union):This position is in the collective bargaining unit.

Position Designation:The incumbent of this position will be subject to enhanced suitability screening pursuant to Section 411 of Chapter 4 of DC Personnel Regulations, Suitability – Protection Sensitive.

Emergency Designation:This position has been designated as Emergency.Employees occupying positions designated as Emergency are required toprovide advice, recommendations, and/or specific functional support necessary for the continuity of operations during a declared emergency.Report to their duty station, when activated, on time and as scheduled when a situation or condition occurs during non-work hours, and results in the late arrival or closing of District government offices for non-essential/non-emergency employees.

EEO Statement: The District of Columbia Government does not discriminate or retaliate in employment on the basis of race, color, religion, sex, pregnancy, gender identity and expression, national origin, family responsibilities, political affiliation, sexual orientation, marital status, homeless status, disability, genetic information, age, membership in an employee organization, participation in a legally protected activity, parental status, matriculation, personal appearance, credit information, status as a victim or family member of a victim of domestic violence, sexual offense, or stalking, military service, or other non-merit factor.