The main role of the Community Transition Liaison - (Nursing Home to Community Coordinator) is to promote, educate, identify, and assist nursing home residents with options related to transitioning into the community.

Responsibilities:

• Meet with residents to increase awareness of community supports and services and introduce transition as a potential option.
• Identifies individuals appropriate for the program based on resident’s desire to transition to community living environment.
• Assist residents to determine the most appropriate supportive program and determine eligibility to ensure effective transition to the community.
• Assist with gathering all necessary documentation needed and completion of applications for housing and other public benefits.
• Manage the discharge process along with purchasing goods and services for transition.
• Have knowledge of and work closely with community partners of State programs to maximize resources and eligibility for services.
• Maintain regular communication with supervisor and nursing staff for expedited clinical screenings and care planning to support community planning and transition.
• Onsite point of contact for residents, families, skilled nursing facility (SNF) staff and all other parties involved with resident’s care for nursing facility transitions to the community.

Essential Functions/Qualifications:

• Bachelor’s degree in Social Work, Human Services or related field, preferred.
• Experience and/or strong interest in the field of human services via previous employment, internship, volunteer activity and/or additional studies.
• Regular and reliable attendance.
• Valid driver’s license and/or reliable transportation; insurance verification and motor vehicle record check.