Diversion/Transition Coordinator

Diversion/Transition Coordinator (Preadmissions Screening Specialist) REQ-156828

Salary range: $4338 - $6635

Grants Pass

We are proud to be an Equal Opportunity Employer. We are actively working to build an equitable agency with the  as our guide toward our vision of an agency free of discrimination and bias. We believe that teams in which everyone can show up as their full authentic self are key to creating a thriving workforce that can better serve communities. We welcome members of historically underrepresented racial/ethnic groups, women, individuals with disabilities, veterans, LGBTQIA2S+ community members, and others to apply.

Do you want the opportunity to match the needs of people in the community with available federal, state and local programs or other resources to meet those needs?  Do you want to be part of a diverse workforce that collaborates and learns from each other to improve services that supports the elderly, people with disabilities and communities?  Then, we want to hear from you

Aging and People with Disabilities (APD), part of the Oregon Department of Human Services, is seeking a dedicated and compassionate individual for a Diversion/Transition Coordinator (Preadmissions Screening Specialist).

Oregon Department of Human Services (ODHS), A place to belong and make a difference 

• When you join the , you join a community of over 10,000 employees dedicated to serving and helping Oregonians achieve wellbeing and independence through opportunities that protect, empower, respect choice, and preserve dignity.  

• Connect with ODHS Employee Resource Groups (ERGs) and find a place to belong, build community and participate in shared learning. ERGs are employee-driven committees that support each other as well as the ODHS’ overall mission and vision.   

• Enjoy a work-life balance, 11 paid holidays a year, flexible work schedules, and including health, dental, vision and much more  

Oregon Department of Human Services (ODHS), A place to belong and make a difference 

• When you join the , you join a community of over 10,000 employees dedicated to serving and helping Oregonians achieve wellbeing and independence through opportunities that protect, empower, respect choice, and preserve dignity.  

• Connect with ODHS Employee Resource Groups (ERGs) and find a place to belong, build community and participate in shared learning. ERGs are employee-driven committees that support each other as well as the ODHS’ overall mission and vision.   

• Enjoy a work-life balance, 11 paid holidays a year, flexible work schedules, and including health, dental, vision and much more  

ABOUT THE PROGRAM

to learn more about Aging and People with Disabilities.

YOUR DUTIES AT A GLANCE:

In this position you will provide various types of services: Diversion and Transition through the Home and Community Based Care "C" waivered programs and nursing facilities (NFs) 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 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. 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. 

Major duties include:

Complete initial and/or ongoing assessment or monitoring interviews with the applicant/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:

1)  Accept referrals from sources such as case managers, intake workers, managers, hospital discharge planners, nursing facilities, Diversion / Transition Team members, etc. 

2)  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. 

3) monitoring of clients during nursing facility skilled care days for potential of diversion. 

4)  monitoring of long-term care nursing facility application/clients for transition potential. 

5)  verifying program eligibility criteria for waiver, or LTC nursing facility care. 

6)  working with local eligibility / case management staff to establish Medicaid financial eligibility. 

7)  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. 

8)  recording findings on appropriate APD assessment forms and narratives. 

9) 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.  

10)  take responsibility for developing a Person-Centered Plan of Care that meets the client’s needs and choice, within agency restraints. 

11) establishing a process for communication with application/client, family and/or guardian, significant others, and facility staff.

12)  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.  

13)  working with project staff, policy teams and/or resource developers to recommend and implement strategies to minimize barriers to client’s diversion or transition. 

14)  upon transition or diversion, following the client for the required period of time for the specific program.  

15)  acting as a consultant to case managers regarding diversion or transition activity or need for long term nursing facility authorization. 

16)  ensuring the agency’s mission, philosophy, and goals of encouraging independence, dignity, choice, safety, and quality of life to every applicant/client is maintained.

WORKING CONDITIONS

This position will usually work a standard work week.  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.

WHAT YOU NEED TO QUALIFY/MINIMUM QUALIFICATIONS (MQ’s):

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 below.

** Please identify by the number 1-9 which of the items in the list that you have experience with.

         
1) Medical and psycho-social problems of the elderly and disabled.
2) Normal and abnormal human development and behavior.
3) Appropriate intervention methods for the elderly and disabled.
4) Medical terminology and procedures.
5) Implications of illness or injury upon clients and families.
6) State and Federal rules about long-term care, medical services, and clients' rights.
7) Policies and procedures about agency programs.
8) Available community resources.
9) Crisis intervention, counseling, being an advocate, community relationships, and/or referral methods.

ESSENTIAL ATTRIBUTES (EA's):

• Excellent people/customer services skills. 

• Experience working with the aged and/disabled population. 

• Excellent communications skills to be able to discuss/assess client need. 

• Experience problem solving and making decisions while adhering to policy.

• Experience preparing and maintaining written documentation of actions taken or needed.

• Experience obtaining information through interviews.

• Experience completing tasks that are time sensitive.

APPLICATION INSTRUCTIONS and REQUIREMENTS

• Clearly describe how you meet the minimum qualifications (MQ’s) and essential attributes (EA’s) within your application materials. These attributes will be used to determine which candidates will be selected to move forward in the process. 

• Please upload a resume or complete the Workday history profile. Your work history profile and/or resume are the perfect opportunity to highlight your interest in the position and showcase your skills and experience that make you the best candidate for the position. Note: Your resume and cover letter may be uploaded in the Resume/CV field on the online application.

• Current State of Oregon employees: Apply via your employee Workday account.

• After you submit your application, you will have additional tasks to complete in Workday. Please continue to check your Workday account throughout the recruitment process.

• Finalists for this position will be subject to a computerized criminal history and abuse check.  Adverse background information will be reviewed and could result in withdrawal of a conditional job offer or termination of employment.

• The Oregon Department of Human Services does not offer visa sponsorship. Within three days of hire, you will be required to complete the US Department of Homeland Security’s I-9 form confirming authorization to work in the United States. ODHS will use E-Verify to confirm that you are authorized to work in the United States.

• A valid driver’s license and acceptable driving record may be required if driving is a duty of this position.

HELPFUL INFORMATION

• This position is represented by the Union (SEIU).

• This recruitment may be used to fill future vacancies.

• Have questions about Workday, and want some tips on understanding the state application process? Check out our page.

• If you need an accommodation under the Americans with Disabilities Act (ADA), have questions or need assistance with the application process, please contact .