Care Transitions Specialist
1 month ago
Hours Per Week: 35
Hybrid role and Will be doing home visits in the Bronx
Duties and Responsibilities:
- Under the direction of a Health Home Supervisor, JASA's Health Home Plus Care Transitions Specialist is responsible for the provision of intensive case management, outreach, care coordination, and crisis intervention for a caseload of mentally and/or physically impaired clients. In accordance with the standards of the social work profession, agency policies, and requirements of the funding source, the role requires key skills and knowledge for serving high need individuals with Serious Mental Illness (SMI).
- The Health Home Plus Care Transitions Specialist will perform the duties listed below:
- Conduct appropriate screening and either perform or arrange for more detailed assessments when needed (e.g., high-risk substance use or mental health related indicators, harm to self/others, abuse/neglect and domestic violence). Conduct triage for emergency intervention; ascertains short-term needs; and provides accurate and appropriate information and referral services to clients, families, and collaterals.
- Provide in-home, in-office, and community assessments of the social and emotional needs of the adult client and his/her family; utilize prescribed standardized Health Home assessment instruments; and secures appropriate assistance of other social work and/or professional consultants.
- Develop and implement written case plans to provide a full range of social services for older adult clients and family, including:
- Provides individual and family counseling and guidance to resolve problems of the client(s) and family.
- Prepares and disseminates appropriate information to clients and collaterals regarding the normal physical, social, and psychological development of individuals, challenges to functioning presented by conditions of impairment, disease, social stresses and dysfunction, and suggests methods used to cope and preserve individual functioning and autonomy.
- Prepares specific information about health, welfare, education and recreation services available to serve the older client.
- Screens client eligibility and applications for appropriate benefits and entitlement.
- Arranges for direct provision of services such as homemaker, home health aide, public assistance, Medicare, Medicaid, emergency cash relief, legal aid, protective services, vocational placement, medical and psychiatric examination and therapy, housing, etc.
- Evaluates clients' capacity to manage their own affairs and protect themselves from financial exploitation.
- Coordinates care with medical and mental health providers; identifies providers, assists with securing appointments, participates in care plan meetings, etc.
- Refer to, and maintain a cooperative relationship with, other community agencies to meet the needs of clients.
- Conduct ongoing monthly in-home visits to evaluate client functioning, monitor risk, assess the status of current services, and update and revise the case plan; seeks appropriate guidance from the supervisor in situations requiring clarification and consultation.
- Extended Hours and Emergency Schedules:
- May be called upon to respond to an after hours client crisis.
- Supervise community aides, interns and volunteers.
- Represent and interpret the agency at community conferences and meetings.
- Participate in training and unit meetings.
- Complete required case records, reports and statistics within mandated time frames, utilizing required Health Home dashboard and JASA EHR systems.
- Handles special assignments and duties as assigned.
- Create and leverage relationships with critical behavioral health service providers to plan and coordinate care management needs for high-need SMI individuals including:
- Navigating the mental health service system-including ability to make referrals to mental health housing services, crisis intervention/ diversion, peer support services
- Knowledge of the behavioral health managed care benefit package and coordinating care with MCOs (e.g., for HARP members)
- Collaborates with inpatient staff and MCO (as applicable) to affect successful transitions out of inpatient or institutional settings
- Addressing the quality, adequacy and continuity of services to ensure appropriate support for individuals' mental health and psychosocial needs.
- Maintain engagement with individuals who are often disengaged from care, have difficulty adhering to treatment recommendations, or have a history of homelessness, criminal justice involvement, first-episode psychosis and transition-age youth. Key skills and practices to engage high-need SMI individuals include but are not limited to:
- Motivational Interviewing
- Suicide Prevention
- Risk Screening
- Trauma Informed Care
- Person-centered care planning and interventions
- Recovery-Oriented Approaches (e.g., Wellness Recovery Action Plans)
Education and Experience:
- International Medical Graduate (degree)
- A Bachelor's degree in one of the qualifying fields below and two (2) years of Experience; OR (Qualifying fields include education degrees featuring a major or concentration in: social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation or recreation therapy, counseling, community mental health, child and family studies, sociology, speech and hearing or other human services field.)
- A Credentialed Alcoholism and Substance Abuse Counselor (CASAC) and two (2) years of Experience; OR A Bachelor's degree or higher in ANY field with either: three (3) years
- Experience, or two (2) years of experience as a Health Home care manager
-
Elder Care Transition Specialist
2 months ago
New York, United States Riverside Community Care Full timeWe make a difference - in your community and in your career. Elder Care Transition Specialist ACCS provides wraparound support through an integrated team of both clinical and peer professionals. The goals of the service include skill and resource development, connection with community and natural supports for successful tenure in the community of the...
-
Care Transition Specialist
2 weeks ago
New York, New York, United States Village Care Full timeJob DescriptionWe are seeking a highly skilled RN for our Transition of Care opening. As a key member of our team, you will play a vital role in ensuring safe and effective transitions between care settings.Your responsibilities will include:Conducting comprehensive assessments to identify Members at risk of hospitalizationEvaluating discharge plans and...
-
Member Services Transition Specialist
4 weeks ago
New York, United States Village Care Full timeTransition SpecialistVillageCareMAX - 112 Charles Street, New York, NY 10014VillageCareMAX is looking for a motivated individual with strong Healthcare experience for our Full Time Transition Specialist position. This role is responsible for ensuring that authorizations for new enrollments are entered timely and accurately per the enrollment assessment and...
-
Care Transitions Specialist
1 week ago
New York, United States Jewish Association Serving the Aging Full timeShift Schedule: Monday-Friday 9AM-5PM Hours Per Week: 35 DUTIES AND RESPONSIBILITIES: JASA's Care Transitions Specialist (CTS) will coordinate, screen and facilitate the provision of home and community-based support services to improve hospital to home care transitions to avoid preventable 30-day readmissions. The CTS, an International Medical Graduate, must...
-
Healthcare Transition Specialist
4 weeks ago
New York, New York, United States Option Care Health Full timeJob OverviewAt Option Care Health, we're committed to delivering exceptional care and services to patients across the nation.About the RoleWe're seeking a seasoned Clinical Transition Specialist to join our team. As a key member of our organization, you'll play a vital role in promoting our services and ensuring seamless transitions for patients.This...
-
Elder Care Transition Specialist
1 month ago
New York, New York, United States Riverside Community Care Full timeJob SummaryWe are seeking a skilled Elder Care Transition Specialist to join our team at Riverside Community Care. As an essential member of our integrated team, you will provide wraparound support to individuals enrolled in our Adult Care Consultation Services (ACCS) program.The ideal candidate will possess excellent assessment and consultation skills, with...
-
Transition of Care Registered Nurse
2 weeks ago
New York, New York, United States Village Care Full timeVillageCare is seeking an experienced Transition of Care Registered Nurse to join our team. In this role, you will work closely with our interdisciplinary team to ensure seamless transitions for our members. With a strong focus on patient-centered care, you will leverage your expertise to develop and implement workflows that promote optimal Member...
-
Care Transitions Specialist
2 weeks ago
New York, New York, United States NYC Health Hospitals Full timeAbout the RoleThis is an exciting opportunity to join our team as a Healthcare Director, leading the development and implementation of transitional care programming and supporting the delivery of high-quality care to vulnerable populations. You will work closely with hospital and Central Office leadership, ED Care Management, ED Social Work, inpatient...
-
Bridge Transition Specialist
4 weeks ago
New York, New York, United States Community Access Inc Full timeEmpower Lives with Community AccessFounded in 1974, Community Access is a pioneer of supportive housing and social services in NYC for individuals with mental health concerns. We lead advocacy efforts promoting human rights, social justice, and economic opportunities for all.Our programs span across 25 locations, offering over 1200 units of supportive...
-
Transitional Housing Specialist
2 weeks ago
New York, United States Women In Need, Inc. Full timeAbout the RoleAs a Transitional Housing Specialist at Women In Need, Inc., you will have the opportunity to make a meaningful difference in the lives of our clients.Your primary responsibility will be to provide comprehensive support services to families residing in our transitional housing programs.You will work closely with our social service team to...
-
Care Coordination Specialist
3 weeks ago
New York, New York, United States NYC Health Hospitals Full timeJob SummaryWe are seeking an experienced RN Healthcare Navigator for Transitions to join our team at MetroPlusHealth. As a key member of our care coordination team, you will play a vital role in ensuring that our members receive high-quality, patient-centered care throughout their healthcare journey.Key Responsibilities:Assess member needs and develop...
-
Transition Specialist
3 days ago
New Orleans, United States Orleans Parish Sheriff's Office Full timeAbout the Role: As a Transition Specialist at our Public Administration organization, you will play a critical role in ensuring the successful re-entry of incarcerated individuals into society. You will be responsible for developing and implementing transition plans that address the unique needs of each individual, including housing, employment, and...
-
Care Transition Coordinator
1 week ago
New York, New York, United States Harlem United Community AIDS Center Inc Full timeJob Title: Care Transition CoordinatorSalary: $50,000 - $65,000 per year.About the RoleWe are seeking a highly motivated and organized Care Transition Coordinator to join our team at the Harlem United Community AIDS Center Inc. As a key member of our staff, you will play a critical role in ensuring a smooth transition for clients from intake to assigned care...
-
Transitions of Care Manager RN
2 months ago
New York, United States MetroPlusHealth Full timeEmpower. Unite. Care.MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.About NYC Health + HospitalsMetroPlusHealth's provides the highest...
-
Transitional Living Specialist
2 months ago
New Bern, United States Methodist Home for Children Full timeTransitional Living Specialist Full Time New Bern, NC, US YesterdayRequisition ID:1108 Apply Salary Range:$43,000.00 To $47,000.00 Annually Transitional Living Specialist Join a Mission-Driven Organization! Methodist Home for Children (MHC) is dedicated to ensuring safe, nurturing homes for children while addressing the root causes of abuse, neglect,...
-
Rx Care Specialist
2 weeks ago
New York, New York, United States Care Well RX Inc Full timeCare Well RX Inc is seeking an experienced Rx Care Specialist to join our team. As an Rx Care Specialist, you will be responsible for filling prescriptions, dispensing medication, counseling patients, and consulting with physicians. We offer an estimated salary of $125,000 - $155,000 per year. In this role, you will have the opportunity to make a meaningful...
-
RN- Transition of Care
2 weeks ago
New York, United States VillageCare Full timeRegistered Nurse- Transition of Care 100% Remote VillageCare is looking for a self-motivated and passionate RN for our Full Time Transition of Care opening. The Transition of Care Nurse is responsible to ensure safe and effective transfer in the movement of Members across the care continuum, serving as a bridge between professional staff in the care...
-
RN- Transition of Care
2 weeks ago
New York, United States VillageCare Full timeRegistered Nurse- Transition of Care100% RemoteVillageCare is looking for a self-motivated and passionate RN for our Full Time Transition of Care opening. The Transition of Care Nurse is responsible to ensure safe and effective transfer in the movement of Members across the care continuum, serving as a bridge between professional staff in the care setting...
-
RN- Transition of Care
2 weeks ago
New York, United States VillageCare Full timeRegistered Nurse- Transition of Care100% Remote VillageCare is looking for a self-motivated and passionate RN for our Full Time Transition of Care opening. The Transition of Care Nurse is responsible to ensure safe and effective transfer in the movement of Members across the care continuum, serving as a bridge between professional staff in the care setting...
-
Transition of Care Supervisor
2 weeks ago
New York, New York, United States VNS Health Full timeJob SummaryVNS Health is seeking a Transition of Care Supervisor to lead our clinical and non-clinical support teams. This role requires strong leadership and communication skills to ensure efficient clinical operations and customer satisfaction.ResponsibilitiesAs a Transition of Care Supervisor, your duties will include:Overseeing the day-to-day operations...
