Transition Coordinator

Alternatives is a private, non-profit organization serving sixteen counties in Midwestern Illinois. Since 1984, our mission has been to promote the independence and quality of life for older adults, adults with disabilities and their families. Alternatives' professionals are connecting with ONE IN FIVE individuals over the age of 60 in a sixteen-county region.

BASIC PURPOSE/SCOPE:

Primary liaison with assigned hospital and nursing facilities to create successful transitions from facility to home through enhanced service coordination. Provide Comprehensive Care Coordination services to older individuals, their families, and/or caregivers as defined by the program. Coordinate with all appropriate medical providers post discharge. Maximize an individual’s potential and promote their independence to the greatest extent possible through effective service and resource coordination.

PRINCIPLE RESPONSIBILITIES:

Coordination With Hospital/Nursing Facility

Coordinate with facility and medical providers to develop plan of care that will improve care transitions and reduce risk of readmission. Provide monitoring and follow up of individuals who have discharged from facility to assure individual needs are being met and care plan is being implemented.

Create individualized, goal-oriented plans of care through Comprehensive Care Coordination Assessments and Reassessments.

Conducts comprehensive care coordination assessments and reassessments to evaluate the individual’s strengths, supports and service needs which are reflected in case documentation. Determines eligibility for the Community Care Program and maintains certifications for such. Develops an individualized goal-oriented plan of care with the individual to meet his/her needs. Advocates for the individual as needed.

Choices for Care Screenings.

Conducts timely Choices for Care screenings for hospitals/nursing facilities as appropriate and evaluates potential for diverting individuals to the community with supportive services. To assure compliance with Illinois Department on Aging timelines and regulations, will assist to provide weekend coverage for required pre-screens.

Program Compliance and Billing.

Utilize data collection systems to provide quality measures of the transition coordination process. Completes work within contract, grant, and program requirements (includes meeting all timelines, response to complaints, etc.) Meets required productivity levels monthly. Completes billing in a timely manner, minimizing outstanding monthly cases.

Resource Knowledge and Networking.

Demonstrates knowledge about resources in the community and develops relationships with provider agencies, medical providers, hospitals and nursing facilities to enhance visibility and to work collaboratively around systems issues, gaps in services, and special needs and makes referrals as appropriate. Works collaboratively and cooperatively with programs within Alternatives.

Professional Development.

Participates in activities and educational opportunities leading to own professional development (within and outside the agency) to include training related to transition coordination pilot programs. Meets annual educational requirements for the position.

All other duties as assigned.

Assist to assure smooth operations of services in alignment with agency mission and to complete other related tasks as assigned. Develop a plan to staff with supervisor for handling emergency or crisis situations.

JOB REQUIREMENTS:

Bachelor’s degree in social work, nursing, social science or related field from a four-year college or university and six months related experience in health or social services or a RN with 20 CEU’s of related courses in health or human services and two years related experience in health or social services. Strong interpersonal and time management skills. Current driver’s license and car required.

SUPERVISOR: Works under the direction of Associate Director of Care Coordination.

Job Type: Full-time

Pay: $20.00 per hour

Benefits:

• Dental insurance
• Employee assistance program
• Flexible schedule
• Health insurance
• Life insurance
• Paid time off
• Parental leave
• Tuition reimbursement
• Vision insurance

Education:

• Bachelor's (Required)

Ability to Commute:

• Moline, IL 61265 (Required)

Work Location: In person