Preadmissions Screening Specialist (Transition Coordinator)
Human Services-Seniors & People with Disabilities - Oregon City, OR

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The Department of Human Services (DHS) is about safety, health and independence for all Oregonians. We help Oregonians in their own communities achieve well-being and independence through opportunities that protect, empower, respect choice and preserve dignity. We protect children who are abused or neglected. We serve seniors, people with disabilities. We help low-income people along the road to self-sufficiency with health coverage, job preparation, childcare and other supports. Our services are delivered in the least restrictive setting and in partnership with communities. We are absolutely committed to ongoing innovation in the delivery of services, and we are committed to recruiting, developing and retaining dedicated employees.

This employment opportunity is with Aging and People with Disabilities, which is part of the Department of Human Services. There is one permanent full-time opening located in Oregon City (Molalla Ave). This position is represented by a union.

This recruitment announcement will be used to establish a list of qualified candidates to fill the current vacancy and may be used to fill future vacancies as they occur.

Please be aware that due to the economic downturn and subsequent state budget short-fall these positions may be required to take furloughs in the biennium 2011-2013.

Duties & Responsibilities:

The purpose of this position is to provide various types of services: Diversion and Transition through the Home and Community Based Care programs, and nursing home authorizations. Diversion services are provided to prevent a person from becoming a long term resident of a nursing facility, prior to Medicaid funding covering the cost of care. Diversion can begin prior to nursing facility placement or while a person is receiving skilled Nursing Facility (NF) care.

A person residing in a nursing facility and/or acute care hospital, with Medicaid funding covering the cost of care is eligible for Transition services. These services may be provided to enable a client to move from the nursing facility into Home and Community Based Care (HCBC) care, if the client has been in the nursing facility or acute care hospital.
Emphasis of this position is given to the development and implementation of care plans in the least restrictive setting, ensuring the client's choice, dignity, independence, and quality of life.

Complete initial or ongoing assessment or monitoring interviews with the applicant or client to secure social, medical, psychosocial, and personal data to determine potential for diversion or transition, and/or for completion of the pre-admission screening for nursing facility care authorization. The purpose of this interview is to ensure the applicant/client has knowledge regarding all HCBC and nursing facility options and programs to allow for person centered plan of care development to ensure client choice, safety, dignity, independence and quality of life.

The Transition Coordinator’s duties include, but are not limited to:
  • Accepting referrals from sources such as case managers, intake workers, managers, hospital discharge planners, nursing facilities, Diversion/Transition Team members, etc.;
  • Scheduling field visits and interviews with applicant/client, involving family, guardian, etc. to explain the diversion and waivered transition program and concepts, and nursing facility long term care;
  • Monitoring of clients during nursing facility skilled care days for potential of diversion;
  • Monitoring of long term care nursing facility application/clients for transition potential;
  • Verifying program eligibility criteria for waiver, or Long Term Care (LTC) nursing facility care;
  • Working with local eligibility/case management staff to establish Medicaid financial eligibility;
  • Gathering of data by reviewing previous medical case files, current medical and facility records, as well as interviewing the applicant/client and collateral contacts such as physicians, nursing staff, facility staff, mental health, family members and natural supports;
  • Recording findings on appropriate Aging and People with Disabilities (APD) assessment forms and narratives;
  • Organizing, evaluating, staffing with local Diversion/Transition Team in drawing conclusion of applicant/client’s level of care and service need from the data, and through the application of the Transition Coordinators knowledge, judgment, and experience;
  • Take responsibility for developing a Person Centered Plan of Care that meets the client’s needs and choice, within agency restraints;
  • Establishing a process for communication with application/client, family and/or guardian, significant others, and facility staff;
  • Communicating the proposed plan of care to other involved parties, such as nursing facility staff, HCBC facility care provider, Home Care Worker (HCW), discharge planner, contract agency, home health, housing staff, local Diversion/Transition Team, etc.;
  • Working with project staff, policy teams and/or resource developers to recommend and implement strategies to minimize barriers to client’s diversion or transition;
  • Upon transition or diversion, following the client for the required period of time for the specific program;
  • Acting as a consultant to case managers regarding diversion or transition activity or need for long term nursing facility authorization; and
  • Ensuring the agency’s mission, philosophy, and goals of encouraging independence, dignity, choice, safety, and quality of life to every applicant/client is maintained.
Complete and enter data on all required Preadmission Screening (PAS), Diversion and Transition related forms within appropriate time lines; completes required statistical reports; keep the District Manager informed of problems and performance of job; observe all APD policy and procedures at the unit, district and state levels; attend all trainings, as requested; participate, as requested in the training of APD staff and interested community partners and providers.

Assure that service delivery is provided in a culturally competent way; assure that printed materials are available in different languages and/or in alternate format; bi-lingual services available and facilities are accessible for all clients.

Cooperate, communicate, and promote good working relationships with project staff, policy teams and/or resource developers, the local Diversion/Transition Team, peers, and community partners and providers, i.e. Social Security, Area Agencies on Aging (AAA), Veterans Affairs (VA), Self Sufficiency, HCBC providers, Vocational Rehabilitation (VR), Contract Agencies, etc.

Counsel clients regarding availability of other resources; attend and participate in staff and Diversion/Transition meetings.

Other duties as assigned


This position will usually work a standard workweek. Some irregular hours may be encountered as a result of client needs. Day travel will be regularly required within the service area; some overnight travel may be required for training. This position requires a valid driver's license or other acceptable method of transportation. Travel may be in inclement weather. This position will require the ability to work on tasks simultaneously, sometimes with short time frames and will require regular contact with a variety of people, including families and self-advocates; DHS and other state employees; employees of local governments; stakeholders and consumer advocates; long-term services and health care providers, and employees of other state governments and of the federal government.

Qualifications & Desired Attributes:

Your application materials, including your answers to the 'Supplemental Questions' will be reviewed to determine if you meet the minimum qualifications and how you meet the desired attributes for the position to which you have applied. Your answers to the supplemental questions must be reflected in your application.


Six months of experience providing services to persons who are elderly or disabled; AND

Training and experience which shows knowledge of at least four (4) of the areas listed:
  • Medical and psychosocial problems of the elderly and disabled.
  • Normal and abnormal human development and behavior.
  • Appropriate intervention methods for the elderly and disabled.
  • Medical terminology and procedures.
  • Implications of illness or injury upon clients and families.
  • State and Federal rules about long-term care, medical services, and clients' rights.
  • Policies and procedures about agency programs.
  • Available community resources.
  • Crisis intervention, counseling, being an advocate, community relationships, and/or referral methods.
NOTE : RN or MSW desirable but not required.


Experience working in a human or social services related field.

Professional training in social work, community counseling, public health, gerontology or other human service areas.

Experience working with placing clients discharged from a hospital into a new community setting.

Experience working in a human or social service setting coordinating care with hospital, nursing facility or community care services.

Knowledge of community based resources.

Experience interviewing to obtain data for a human or social services program.

Experience preparing and maintaining written narrative documentation of the activities concerning individual client cases.

Only the candidates whose experience most closely match the qualifications and desired attributes of this position will be invited to an interview.

Additional Information:

IMPORTANT NOTICE – Email Addresses Now Required

The state of Oregon is now requiring all applications have a valid email address.

If you do not currently have an email address and do not know where to go to get one please refer to our Applicant E-Recruit FAQ's web page. Click on the link below to go directly to question #14 to view several internet providers where you can get a free e-mail account. The state of Oregon does not endorse any particular provider.
Applicant E-Recruit FAQ's

If you are offered employment, the offer will be contingent upon the outcome of an abuse check, criminal records check and driving records check, and the information shall be shared with the DHS, Office of Human Resources (OHR). Any criminal or founded abuse history will be reviewed and could result in the withdrawal of the offer or termination of employment.

DHS will communicate with all applicants via e-mail.

If you need assistance to participate in the application process, you are encouraged to call 503-945-5698 (voice) 8:00 a.m. and 5:00 p.m. (Pacific Time) Monday through Friday. TTY users please use the Oregon Telecommunications Relay Service: 1-800-735-2900.

If you need assistance with adding attachments to your profile or to a specific job posting please go to Adding and Removing Attachments to a Profile and Job Posting for further instructions. This quick help guide can also be found on the State Jobs Page by clicking in the Applicant E-Recruit FAQ's then click on Applicant Profile Maintenance.


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State of Oregon - 23 months ago - save job