Transitions Coach/ Social Worker

OCES supports elders and individuals with disabilities by providinginformation and coordination of services promoting healthy, safe livesfor our consumers. We want to help them stay as active and engaged intheir lives and in their own communities. OCES is looking for aTransitions Coach, responsible for providing transitional coaching toeligible patients/consumers to create a smooth transition from hospitalto home. Check out our web site (www.ocesma.org) to see what ourTransitions Department and other OCES programs are doing to support theneeds of our consumer base! What you\'ll do: Participate in hospital leddischarge planning meetings Work with consumers to understand theirdischarge plans after a hospital stay Meet with consumers in their homefollowing a hospital discharge and follow up with consumers for 30 dayspost-discharge from the hospital Carry a rotating caseload of 24consumers Work closely with Blue Cross Blue Shield (BCBS) RN CareManagement team Make referrals to BCBS program such as care management,dietician, behavioral health, Alzheimer\'s, member services Attendtraining specific to understanding and using the Eric ColemanTransitions Model Assist consumer\'s in identifying needs in thecommunity and make appropriate referrals to additional HCBS servicesEngage in a monthly virtual coach meeting with other Transitions Coachesthroughout the state Maintaining case records in compliance withregulations, standards, and protocols Maintaining knowledge of currentOCES policies and standards, and funding source regulations What you\'llbring: Bachelor\'s degree in nursing, social work, human services, orrelated field highly preferred Knowledge of long-term care, casemanagement, discharge planning, community resources, programs, andbenefits to help support an individual\'s transition from aninstitutional to a community setting. Two years of experience in thesocial services field including a minimum of one year of experience withtransition support activities. Excellent verbal and writtencommunication skills. Interpersonal and conflict resolution skills.Organizational skills and attention to detail. Strong analytical andproblem-solving skills. Strong supervisory and leadership skills.Proficient with Microsoft Office Suite or related software. Ability totravel and reliable means of transportation. Must have a personalcomputer with secure internet access at home. What you\'ll get: Abilityto work with an enthusiastic team of like-minded individuals Opportunityto develop professionally in your chosen career Great work/life balance:35-hour work week with some flexibility. Hybrid work environment (homewith some in-office requirements) Exceptional benefits: health benefitsavailable on day 1; generous paid time off policies; company paid LTDand life insurances, 401K plan