Transitions Coach/Social Worker

OCES supports elders and individuals with disabilities by providing information and coordination of services promoting healthy, safe lives for our consumers. We want to help them stay as active and engaged in their lives and in their own communities.

OCES is looking for a Transitions Coach, responsible for providing transitional coaching to eligible patients/consumers to create a smooth transition from hospital to home.

Check out our web site (www.ocesma.org) to see what our Transitions Department and other OCES programs are doing to support the needs of our consumer base!

What you'll do:

• Participate in hospital led discharge planning meetings


• Work with consumers to understand their discharge plans after a hospital stay


• Meet with consumers in their home following a hospital discharge and follow up with consumers for 30 days post-discharge from the hospital


• Carry a rotating caseload of 24 consumers


• Work closely with Blue Cross Blue Shield (BCBS) RN Care Management team


• Make referrals to BCBS program such as care management, dietician, behavioral health, Alzheimer's, member services


• Attend training specific to understanding and using the Eric Coleman Transitions Model


• Assist consumer's in identifying needs in the community and make appropriate referrals to additional HCBS services


• Engage in a monthly virtual coach meeting with other Transitions Coaches throughout the state


• Maintaining case records in compliance with regulations, standards, and protocols


• Maintaining knowledge of current OCES policies and standards, and funding source regulations

What you'll bring:

• Bachelor's degree in nursing, social work, human services, or related field highly preferred


• Knowledge of long-term care, case management, discharge planning, community resources, programs, and benefits to help support an individual's transition from an institutional to a community setting.


• Two years of experience in the social services field including a minimum of one year of experience with transition support activities.


• Excellent verbal and written communication skills.


• Interpersonal and conflict resolution skills.


• Organizational skills and attention to detail.


• Strong analytical and problem-solving skills.


• Strong supervisory and leadership skills.


• Proficient with Microsoft Office Suite or related software.


• Ability to travel and reliable means of transportation.


• Must have a personal computer with secure internet access at home.

What you'll get:

• Ability to work with an enthusiastic team of like-minded individuals


• Opportunity to develop professionally in your chosen career


• Great work/life balance: 35-hour work week with some flexibility. Hybrid work environment (home with some in-office requirements)


• Exceptional benefits: health benefits available on day 1; generous paid time off policies; company paid LTD and life insurances, 401K plan

APPLY TODAY!

OCES is an open, welcoming organization that respects our diversity. We encourage all qualified persons to apply!

We can't wait to hear from you...So take that next step and apply today!

OCES is celebrating 50 years of service to the Plymouth County area! We are an open, welcoming organization that respects our diversity. We encourage all qualified persons to apply! OCES was named one of C&P Business Media's Best Places to Work 2024!

Our mission: Through the talents of an experienced and diverse workforce, OCES supports the independence and dignity of older adults and individuals with disabilities by providing essential information and services that promote healthy, safe living which positively impacts our community.