Transition Coordinator

Job Description

Join our dynamic healthcare team as a Case Manager, where you will play a vital role in coordinating patient care and ensuring seamless transitions across various healthcare settings. This energetic position offers the opportunity to utilize your clinical expertise, critical thinking, and compassionate communication skills to improve patient outcomes. As a Case Manager, you will collaborate with multidisciplinary teams, manage complex cases, and advocate for patients’ needs within a fast-paced hospital environment.

Your dedication will directly impact the quality of care delivered and help optimize resource utilization. It’s essential to collaborate with one’s care team and circle of care to meet their community objectives and goals.

HOPE “
Helping Others Prosper Everyday
” by advocating through networks of resource solutions and building partnerships to support person-centeredness and informed decision-making for a diverse population, desiring to thrive in their communities.

We strive to support a “customized person-centered” plan of action. Our approach is designed to keep the person first and utilize resources in the community towards meeting their community goals.

We are passionate about the people we serve and the service we provide. We aim to go above and beyond to support others in accomplishing their community goals towards living a self-fulfilling, productive, and stable life in the community.

Our values keep us bounded in service provision. The values of our “HOPE Benefit” are as follows:

• Accountability
• Commitment
• Transparency
• Collaboration
• Connectedness

• Understanding and adhering to program rules and restrictions
• Assessing participants eligibility and determining their housing and service needs
• Assisting participant with efficient searches for available and suitable housing
• Develop a customized, person-centered housing plans with participants
• Provide support aiding in applying for benefits to increase financial independence, various skills ability, access to essential community resources, and connecting with various providers
• Respond to client crisis as they arise and work to problem solve and deescalate situations
• Provide Case Management that includes frequent face-to-face and phone contacts with each participant, per week, with a caseload of approximately 5 participants
• Communicate with case management team members, community professionals, and other service providers to ensure that services for the participant are properly coordinated
• Collaborating with government agencies, community organizations, and property owners
• Preparing and maintaining electronic health records, activity documentation, and reports to ensuring it is in accordance with the expectations for timely and thorough billing and in compliance with HIPPA and Data Privacy Practices

• Investigating and resolving client and landlord issues
• Ensuring participants understand their rights and responsibilities as tenants
• Providing clients with information & refer them to additional support programs or services
• Provide flexible services within a schedule that meets the needs of participants
• Develop individualized care plans that include discharge planning, utilization review, and coordination of services across hospital departments, treatment centers and nursing homes; other qualified settings.
• Represent the organization with a positive and professional image, at all times
• Provides and promotes unconditional positive regard to all participants regardless of race, creed, gender, religion, sexual orientation, disability, and economic status
• Meets performance criteria as outlined in annual performance evaluation
• Participate in staff meetings and meet regularly with program coordinator
Participate in multidisciplinary processes to advocate for appropriate housing and resource allocation within a community based setting, supporting long-term goals
• Support discharge planning by arranging services, equipment, and supports customized to meet the person's needs and stability
• Performs other duties as requested or assigned

• Bachelor's Degree (preferred), or Associate's Degree with 2+ years of Case Management experience
• Reliable Transportation with active auto insurance