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Transitional Care Coordinator
3 months ago
Job Title: Transitional Care Coordinator
Schedule: Full-Time, Monday - Friday (8 AM - 5 PM)
Pay Rate: $28 - $35/hr
About San Francisco Campus for Jewish Living
Nestled in San Francisco's Excelsior neighborhood on a nine-acre campus, the San Francisco Campus for Jewish Living (SFCJL) is a center of excellence in providing a continuum of care. This includes the Frank Residences, offering assisted living and memory care services; the Jewish Home and Rehabilitation Center, featuring long-term skilled nursing, short-term rehabilitation, and an acute psychiatric unit specialized in mental healthcare for older adults over age 55; and the Jewish Home and Senior Living Foundation.
Grounded in the Jewish values of dignity, compassion, and community, the San Francisco Campus for Jewish Living, fondly referred to in the past as "the Jewish Home," was founded in 1871. Today, 150 years later, it continues to build upon its legacy of enriching the lives of older adults.
Position Overview
As a member of the Jewish Home & Rehab Center Care team, the Transitional Care Coordinator (TCC) provides psychosocial support to patients and their families, facilitates discharges, meets documentation requirements and functions as member of the inter-disciplinary team.
Assists in planning, organizing, implementing and evaluating overall operation of the facility Social Services Department in accordance with current federal, state, and local standards, guidelines and regulations, and the facility’s established policies and procedures.
Essential Job Functions
- Coordinate with interdisciplinary team and other departments in provision of social and discharge services.
- Complete comprehensive psychosocial assessment of patients within appropriate timeframe.
- Act as liaison between the patients, their family, other department and community referrals throughout the patient’s stay on the Short-Term Rehab Unit and Long-Term Care.
- Assist patients and families with concrete services.
- Demonstrates knowledge of an ability to utilize community resources.
- With guidance from supervisors, respond to crisis situations as presented by patients, families, and staff.
- Facilitate individual counseling to patients and families as needed.
- Participate in the formulation of patient care plans and develop goals and treatments for social services.
- Encourage residents/responsible parties to participate in the development of their care plan and invite them to care plan meetings accordingly.
- Maintain accurate and timely documentation which complies with federal/state regulations and Jewish Home policy including but not limited to Initial Assessments, Psychosocial/Mental Status Assessments, Care Plans, Social Service Progress Notes and Discharge Planning.
- Maintain confidentiality of necessary information.
- Act as a patient advocate and ensure patients are informed of their rights and responsibilities and insurance benefits, as well as changes that may affect their rights and responsibilities or insurance benefits.
- Other duties as assigned by Director of Social Services.
Qualifications
- A minimum of a bachelor’s degree in social work or other human services field to include, but not limited to, sociology, gerontology, rehabilitation, counseling or psychology.
- Minimum one year of supervised social work experience in a health care setting working directly with individuals.
- Exemplary interpersonal skills and ability to work cooperatively and collaboratively as a member of an interdisciplinary team.
- Ability to communicate effectively with patients and their families, and at all levels of the organization.
- Effective time management skills to organize and prioritize workload.
- Minimum one year of experience with case management and discharge planning.
- Understanding of Medicare/Medi-Cal guidelines.
- Knowledge of medical terminology preferred.
Personal Skills and Traits Desired/Physical Requirements/Working Conditions
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
- Must be a supportive team member, contribute to teams, and exemplify effective, collaborative and supportive teamwork.
- Ability to make independent decisions when circumstances warrant such action.
- Ability to deal tactfully with personnel, residents, family members, visitors, governments agencies/personnel and the public.
- Must have patience, tack, and willingness to deal with difficult residents, family ad staff.
- Must be able to relay information concerning a resident’s condition.
- Must not pose a threat to the health and safety of other individuals in the workplace.
- Must be resourceful.
- Ability to maintain composure in stressful situations
- Maintain a positive attitude and possess the ability to work in stressful situations.
- Ability to be organized and efficient.
- Ability to organize meetings, as well as set and achieve goals.
- Ability to lift, push, pull a minimum of fifteen (15) pounds.
- Ability to exert maximum muscle force to lift, push, pull or carry.
- Ability to use abdominal and lower back muscles over time without fatigue.
- Ability to stand and/or sit for extended periods.
- Ability to bend, stoop, stretch, twist, sit, and reach.
- Fine motor skills.
- Good visual and auditory acuity.
Compliance as a Condition of Employment and Performance Appraisal
Agreement to abide by all standards, policies, and procedures of the facility, including the facility’s compliance and ethics program, is a condition of employment. Compliance will be a factor in evaluating job performance. Violations, including failure to report violations, will result in disciplinary action, up to and including termination.
This job description is intended to convey the general scope of the major duties and responsibilities inherent in this position. Other tasks not listed here may be assigned by the Administrator. Periodic revision may be necessary to reflect changes in expectations placed on long term care by various governmental agencies. This job description will be reviewed and/or revised annually and as needed.
Individual performance will be evaluated using the following scale:
- Unsatisfactory: Achieves results which are far less than the standards identified for the performance factors rated.
- Needs Improvement: Achieves results which are less than the standards identified for the performance factors rated. Exhibits the potential to become a competent performer. May be new to job or need skill development.
- Meets Standards: Achieves results which meet the standards identified for the performance factors rated. This rating is the expected level of performance.
- Exceeds Standards: Achieves results which usually exceed the standards identified for the performance factors rated.
NOTE: This job description is not intended to be all-inclusive. Employee may perform other related duties as negotiated to meet the ongoing needs of this organization.
I have read and understand terms and conditions of this job description. I further understand that by my acceptance of this agreement, it does not change the “at will” nature of my employment, which may only be altered through written notification signed by the President of Jewish Home and myself:ACCEPTED AND AGREED:
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