Care Transitions Coordinator

Care Transitions Coordinator The Care Transitions Coordinator is responsible for ensuring smooth and effective transitions of care for consumers moving between healthcare settings (e.g., hospital to home, or community-based care). This role focuses on reducing readmissions, improving consumer outcomes, and enhancing the continuity of care by coordinating services, educating consumers and families, and collaborating with healthcare and community providers. Schedule: This is a full-time, non-exempt (35 hour/week) position. We offer 4-day work week and hybrid (in-person & remote, required 1-2 days in office) work schedule (once training is complete.) No nights or weekends. Compensation: Starting annual salary range is $60,000- $65,000. Being bilingual is not a requirement for this role, but we recognize it as an asset and offer an additional 6% bilingual designation for Spanish, Haitian Creole, Russian, Vietnamese, Cantonese or Mandarin. With a refreshing culture that is supportive, collaborative, and encouraging of diverse perspectives and backgrounds and a satisfying balance between your work and personal life, why not join the Mystic Valley Elder Services' Team! Depending on your role and your hours, we offer: Flexible scheduling (4, 4.5, and 5 day work schedule options) Competitive salaries Medical, Dental, and Vision 403b Retirement Plan with agency contribution after 2 years of employment 3 weeks accrued Vacation time 3 weeks accrued Sick time 13 Paid Holidays 30 personal hours Ample free parking Tuition reimbursement Employee referral bonuses of up to $2,000 Job Activities Key activities of the position are below. Additional duties may be assigned as required. Top Key Activities: Serve as the primary point of contact for consumers and families during care transitions, ensuring seamless communication between hospitals, primary care providers, home health agencies, health care payors, and community resources. Conduct post-discharge follow-up calls and home visits (as applicable) to assess consumer needs, reinforce discharge instructions, and ensure adherence to treatment and medication plans. Identify potential barriers to care (e.g., transportation, financial, or social issues) and connect consumers with appropriate community resources and support services Documentation is timely and accurate, including consumer and service data in Aging & Disability (A&D) and other required electronic medical records (EMR) Participate in interdisciplinary team meetings and care management. Compile and submit required statistics and reports Top Key Activities: Participate in community education and outreach. Assure consumers are connected to appropriate community programs and services that address social determinants of health. Participate in required orientation and training including ASAP training, hospital orientation and EMR training. Key Success Measures: Consumer satisfaction State, payer and MVES quality and target metrics Qualifications: Bachelor's degree in social work, human services or related field or associate's degree with 5 or greater years relevant work experience can be submitted for portion of degree. Case management and experience with the older adult population preferred Two years of experience in individual needs assessment and care planning, with a focus on eldercare issues and resources, preferred. Required proof of immunizations: negative TB test (has been done within 1 year), MMR (measles, mumps, rubella), Chicken Pox; OR consent to have titer drawn for above immunizations. Annual flu shot, Covid-19 vaccine. Ability to be a self-starter, work independently, and demonstrate flexibility in responding to consumer needs. Ability to be flexible and be able to adapt to, and work effectively in, the culture of a medical environment Excellent interpersonal skills with demonstrated ability to communicate across all levels, including staff, family and external partners Ability to maintain confidentiality while working with sensitive information or in sensitive situations Highly resourceful team player, with the ability to work effectively independently or as a team. Demonstrates a willingness to take on new tasks with a general attitude that no task is too small, impossible, or cannot be improved Expertise in the following platforms: Microsoft Office 365 (Word, Outlook, Teams, Excel, and PowerPoint), Adobe Pro, Zoom and other web-based applications Private Transportation Physical Requirements of the Job: Ability to lift, push, pull and carry objects weighing up to 25 pounds Ability to travel to the community to perform outreach Work requires regular standing, stooping, and bending Mystic Valley Elder Services is an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.