Part Time Community Transition Liaison
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Minuteman Senior Services
Burlington, MA, US
Summary
The Community Transition Liaison supports nursing facility residents in transitioning to community settings by conducting eligibility assessments and facilitating discharge planning. They coordinate with state programs, families, and healthcare professionals to ensure a smooth transition while managing necessary documentation and referrals.
Job Description
Job Details: Job Location: Minuteman Senior Services Inc - Burlington, MA, Salary Range: $26.00 - $26.00Hourly, HOURS PER WEEK: 17.5
GENERAL SUMMARY:
Under the supervision and guidance of the Community Transitions Supervisor, the Community Transition Liaison supports nursing facility residents (ages 22+) who want to consider transitioning to a community setting. This service includes both short-stay admissions and long-term residents. The program involves assisting to meet the unique needs of sub-populations, including those with criminal justice system involvement, behavioral health needs, specific diagnoses and individuals experiencing housing insecurity, and/or those who may require specialized referrals to state programs and supports and to other agencies for transition needs which are best met through other agencies.
ESSENTIAL FUNCTIONS:
Under the direction of the Community Transition Liaison Program Supervisor:
Community Transition Liaison supports nursing facility residents (ages 22+)
Visit with residents to increase awareness of community support and services and introduce transition as a potential option;
Participate in resident and family conversations to inform options and transition plan;
Conduct assessments to determine eligibility and help with planning transition to the community;
Begin the process of gathering all necessary documentation and identification needed for application for housing and other public benefits;
Complete referrals to other programs and follow up on referrals to ensure timely transition;
Identifies individuals appropriate for CTLP based on resident’s desire to transition to community living environment, including use of PASRR portal to facilitate resident identification
Participates and facilitates in discharge planning meetings with the consumer, family, nursing facility staff, and other agencies that will support the consumer in the community upon discharge
Liaison with nursing and other professionals at the SNF; and
Coordinate with state programs and teams
Attend required meetings and complete required trainings
Other duties as assigned
COMPETENCIES NEEDED:
Must be a self-starter and can work in a fast-paced environment with multiple interruptions.
Must possess excellent time management and problem-solving skills, along with the ability to establish and maintain professional boundaries and manage multiple priorities.
Must have accurate and fast data entry computer skills and experience using all Microsoft Suite programs.
Ability to work well with people of all backgrounds, incomes, ages, races, and abilities (i.e., mental health, physical, cognitive, sensory).
WORK ENVIRONMENT:
This job is remote and visiting nursing facilities - occasional office meetings and regularly requires the use of a computer, telephone, and other standard office equipment. When on home visits or other meetings, the employee travels by car and is exposed to changing weather and seasonal conditions.
PHI and PII:
This role has access to Protected Health Information (PHI) and therefore the employee must adhere to Minuteman’s confidentiality policy and HIPAA regulations.
This role has access to Personal Identifiable Information (PII) and therefore the employee must adhere to Minuteman’s confidentiality policy and MA Executive Order 504.
This role has access to Protected Health Information (PHI) and Personal Identifiable Information (PII) and therefore the employee must adhere to Minuteman’s confidentiality policy, HIPAA regulations, and MA Executive Order 504.
Pay Range Disclosure:
In accordance with the Massachusetts Wage Transparency Act, the pay range for this position reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate’s experience, skills, and alignment with the role’s responsibilities.
Qualifications: QUALIFIED APPLICANTS WILL HAVE:
Willingness and sensitivity to work with individuals with complex health needs
Strong interviewing and assessment skills
Ability to listen and create person-centered plans
Strong written and oral communication skills
Ability to manage time in a fast-paced environment with many competing priorities
Strong computer skills include data entry, management of electronic health records, and Microsoft Suite
Familiarity with and/or willingness to learn about all relevant health and human service programs and agencies available
Must possess knowledge of long-term care, case management, discharge planning, community resources, programs, and benefits to help an individual’s transition from an institution to a community setting
Must have reliable transportation and a valid driver’s license in good standing
Minuteman Senior Services is a private, non-profit agency dedicated to helping people of all abilities and backgrounds navigate aging with choice and dignity.
Since 1975, we’ve provided older adults, people with disabilities, and their family caregivers with the information and assistance they need to make informed decisions about their care and support, helping them achieve their goals for living in community.
Our knowledgeable and compassionate staff provides options to meet a wide range of needs for daily living. We empower people to determine how they wish to live their best lives—and we support them on that journey.
Minuteman Senior Services is a federally designated Area Agency on Aging (AAA) and a state-designated Aging Services Access Point (ASAP) through the Massachusetts Executive Office of Elder Affairs, serving people throughout 16 towns north and west of Boston.
Founded
1975
Company size
51-200 employees
Industry
Individual and Family Services
Org type
Nonprofit
Headquarters
Burlington, Massachusetts
Minuteman Senior Services is a private, non-profit agency dedicated to helping people of all abilities and backgrounds navigate aging with choice and dignity.
Since 1975, we’ve provided older adults, people with disabilities, and their family caregivers with the information and assistance they need to make informed decisions about their care and support, helping them achieve their goals for living in community.
Our knowledgeable and compassionate staff provides options to meet a wide range of needs for daily living. We empower people to determine how they wish to live their best lives—and we support them on that journey.
Minuteman Senior Services is a federally designated Area Agency on Aging (AAA) and a state-designated Aging Services Access Point (ASAP) through the Massachusetts Executive Office of Elder Affairs, serving people throughout 16 towns north and west of Boston.
Founded
1975
Company size
51-200 employees
Industry
Individual and Family Services
Org type
Nonprofit
Headquarters
Burlington, Massachusetts