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Transitions Care Manager

Company: AgeSpan
Location: Lawrence
Posted on: September 22, 2022

Job Description:

AgeSpanFormerly Elder Services of the Merrimack Valley/North ShoreAt AgeSpan, you'll find a work environment that combines:

  • A refreshing culture that is supportive, collaborative, and encouraging of diverse perspectives and backgrounds.
  • A focus on innovation with a team recognized for developing and implementing innovative programs and novel solutions.
  • Encouragement of your development through opportunities to get involved, use your voice, and gain new knowledge and skills.
  • A satisfying balance between your work and personal life, including a flexible workplace, generous paid time off, and wellness programs.Depending on your role and your hours, we offer:
    • Flexible schedule and hybrid work opportunities
    • Competitive salaries
    • Healthcare (medical, dental)
    • 403b Retirement Plan with agency match
    • 20 Vacation Days, 12 Sick Days, and 12 Paid Holidays
    • Social Work Licensing Program
    • License Renewal Paid by agency for RN's and Social Workers
    • And MORE!This position is partially remote for the foreseeable futurePosition Responsibilities: To function as a core member of both the Options Team and the Comprehensive Services and Support (CSSM) Team with the focus being to provide decision support to consumers (and their families, if indicated) looking to make informed decisions about their current and/or future care options. This includes providing information and resources to community partners as well assessing the needs of Consumers who have been admitted to a care setting for discharge potential, assessing eligibility for various programs or benefits, educating consumers about their long-term care options and appropriateness for community services, and assisting with their transition back to the community when appropriate.Essential Functions:
      • Assesses a consumer's functional, health, and income status to determine eligibility and appropriateness for community long term care services or programs utilizing a standardized assessment tool.
      • Completes a consumer-oriented needs assessment to identify issues or problems that inhibit secure independent living at home to enable consumers to remain in the community.
      • Works with the CSSM RN to identify those consumers residing in a nursing facility who will be followed by the Transitions CM.
      • Works with the consumer (and family if appropriate) to identify any barriers to discharge from the facility.
      • Works with the consumers, formal, and informal supports to develop a service plan which addresses the consumer's needs.
      • Ensures that consumers have access to public benefits and other community services.
      • Maintains compliance with all mandated regulations of AgeSpan and the state and federal agencies contracted with.
      • Assists with housing search and housing application process.
      • Works in conjunction with Northeast Independent Living Program's Options Counseling staff; including referral sharing and regular communication and meetings.
      • Completes and maintains up-to-date documentation, including case files and statistical records as required by the agency.
      • Assists with discharge planning - including assurance of appropriate housing and set-up in home environment.
      • Conducts post discharge visit to follow up on services and community supports.
      • Attends and participates in supervision, team, Home Care and agency staff meetings as scheduled.
      • Participates in in-service training, educational offerings and workshops to maintain professional expertise and develop additional skills.
      • Other duties as indicated and assigned.Qualifications: BA/BS in social work, human services or related field required; case management and experience with the older adult population preferred; Associates Degree with significant relevant work experience can be substituted for portion of degree. Reliable transportation and valid driver's license required as field work is an essential component of the position.Must be willing and able to complete community assessments on a regular basis and possess good written, verbal, interpersonal and computer skills, and the ability to work in an interdisciplinary team-based environmentHours per week : 37.5AA/EOEAgeSpan is strongly committed to fostering a professional environment that recognizes, respects, and encourages the unique contributions of a broad spectrum of qualified employees. It is important that our employees reflect the diverse communities we serve. We maintain a work atmosphere that allows people of varied backgrounds to grow professionally and contribute to our mission by promoting diversity, equity, inclusion, and work-life balance.

Keywords: AgeSpan, Lawrence , Transitions Care Manager, Executive , Lawrence, Massachusetts

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