Care Transition Specialist / Licensed Social Worker ( Hybrid )

Basic Function: Providing in-home and community, case management services to caregivers of any age, who care for clients who are 18 to 60 years of age or older post-acute hospitalization. Providing Care Transitions support in the community to help community members return home safely and with the services they need instead of becoming institutionalized. Care Transition Specialist are at the heart of the Hospital 2 Home Team (social work driven model). To provide intensive case management and resource coordination to support a safe discharge from acute care and through returning home. To provide support to clients, family members, and all those involved in the care of someone living with Dementia and their caregivers.

Essential Responsibilities:
• Be a leader (reporting directly to the Director of the Hospital 2 Home programming) in Case Management with the Care Transition Specialists and Respite Coachs.
• Provides advocacy and empowers clients and caregivers to make informed long-term decisions as a means to maintain independence.
• Assure adequate supervision and assistance of individual receiving by coordinating set up of Respite Coaching services in the home to relieve caregiver burnout.
• Provide comprehensive, interactive decision support process that examines a consumer’s needs, preferences, values and strengths, which results in a person-centered care plan.
• Gathers sufficient information to accurately identify areas of concern, problems and/or needs and coordinate care with other community partners involved in care (Hospitals, Skilled Nursing Facilities, Community Support Providers).
• Have strong communication skills with diverse groups of individuals.
• Is aware of, and adheres to all elements of the individual care plan.
• Follow established safety precautions in the performance of all duties.
• Provide required documentation in a timely manner, i.e.: Weekly Activity Logs, Client Reports, Mileage Logs, case notes, and all necessary documentation as required by program guidelines.
• Maintain a good working relationship with family of individual for which you are providing services, and with the program director and their designee.
• Meet on a regular basis with your immediate supervisor.
• Work only hours as scheduled and notify your supervisor of any necessary changes.
• Attend training and meetings as requested by supervisor.
• Maintain a working knowledge of the changing needs of senior and disabled populations.
• Any other responsibilities as designated by supervisor.
• Support caregivers in learning how to access community care
• Address concerns in the home with the caregivers and clients in regards to needed supportive services while helping them to learn to do daily tasks in adapted ways.
• Be reactive and supportive to client and caregiver’s needs and attend and support in any safe environment that helps the family (attending medical appointments, helping them grocery shop and pick up prescriptions, meet them at locations to do tours and attend support groups as requested)
• Assess home environments for safety as educated to do and report back to program director with any concerns.
• Provide case management in whatever location the client is in (rehab, skilled nursing, acute hospitals, home, extended families homes, and other locations based on need).
• Support client and caregivers in creating connection with the Hospital 2 Home team and local community. Fight social and medical isolation using communication and connection.
• Be part of a tightly connected team that works closely together to use skills to support client’s and caregivers
• Ability to prioritize and assess urgency, crisis, and need and respond within a quick time frame, with supervision and collaboration of the Hospital 2 Home Team
• Provide clean, clear documentation upon each visit with a client or family member. Document notes of importance and communicate with supervisors when the documentation shows a need that has to be addressed.

Corporate Compliance:
• Maintain confidentiality per HIPPA.
• Adhere to Nevada Senior Services (NSS) professional grooming and dress code regulations.
• Must maintain a working personal cell phone at all times.
• High level of integrity with a strong work ethic.
• Requires installation of QuickBooks time keeping system on personal cell phone.
• Must pass annual Elder Abuse Certification test.
Physical Requirements:
• Position requires lifting, standing, and sitting for extended periods of time.
• Position may be exposed to various environmental conditions (extreme heat, indoor allergens, etc.).
• Current negative 2-step tuberculosis test or Quantiferon test (if positive, must provide chest X-Ray).
• Ability to climb stairs as needed.
• Must be able to lift/move up to 50 pounds.

Minimum Qualifications:
• Must be at least 18 years or older.
• The ability to obtain CPR/First Aid certification.
• Must have reliable transportation, a valid Driver’s License, and current minimum Nevada state required auto insurance.
• Must use personal vehicle for transportation to multiple work locations.
• Ability to pass a background check.
• Must pass a pre-employment physical.
• Must be proficient in English.
• Bachelor’s Degree in Social Work or Human Services Required, Masters Preferred
• Licensed Social Worker in the State of Nevada Preferred
• 2 years working with or exposure to clients living with chronic medical conditions and or chronic cognitive decline (Dementia or related disease).