The Community Transition Liaison Program (CTLP) Case Assistant supports the agency’s Community Transition Liaison and other Home Care Department staff by completing operational, clerical, and administrative tasks to support discharge planning and care transitions. As such, they play a critical role in supporting SNF (Skilled Nursing Facility) residents ages 22+ with activities needed for transition back to the community. The Case Assistant coordinates and gathers documentation needed for public benefits and housing applications. They also assist with referrals, coordination, and follow-up with community agencies and programs to enable SNF residents to achieve their goals and return to the community of their choice. The Case Assistant provides high-quality support to the Liaison and care linkages along with completing reporting and data entry, compliance and referral oversight, and excellent customer service support.
Job Responsibilities and Performance Standards:
- Supports the Community Transition Liaison and Home Care Department Nurses and Case Managers to operate at the top of their roles and responsibilities.
- Accompanies the Liaison and other Home Care Department staff on SNF visits as needed.
- Participates in interdisciplinary case conferences and family meetings to support discharge planning and coordination.
- Works closely with the Liaison to develop and maintain collaborative relationships with SNFs and community service organizations to identify CTLP resident referral opportunities and effectively utilize all available resources for SNF residents who wish to return to the community.
- Gathers, reviews, and submits documentation needed to assist residents in applying for public benefits; this includes but is not limited to, assisting the resident and/or their informal supports with completing and submitting housing and other benefit applications.
- Follows-up on pending applications and referrals to ensure timely completion and ongoing status updates to inform discharge planning.
- Ensures documentation meets CTLP, EOEA, and agency requirements and does so in a confidential and timely manner.
- Reviews and/or completes any reporting and related follow-ups for the CTLP and Home Care Department.
- Ensure compliance with HIPAA regulations including sending, receiving, and maintaining confidential information via phone, email, and fax.
- If bilingual, provide interpretation and translation as needed.
- Perform other duties as assigned.
Professional Standards and Conduct:
- Collaborative and Responsive: Regularly communicate, follow up, and use a team-driven approach. Respond thoughtfully and promptly to agency needs, requests, and inquiries; identify and build partnerships with key stakeholders. Demonstrates excellent organizational and time management skills to meet various deadlines, ensuring closed-loop communication. Ability to multi-task and maintain flexibility to adapt and adjust workload assignments based on various needs.
- Communication: Skilled in verbal and written communication, demonstrating the ability to communicate information in various ways to meet diverse styles and cultural backgrounds.
- Analytical: Critical thinking skills, using logic and reasoning to identify the strengths and opportunities of alternative solutions, conclusions, or approaches to problems.
- Attendance and Punctuality: Dependable, punctual, showing flexibility when needed. Attends meetings as needed and is fully present and participates during those meetings.
- Commitment: Embodies SCES’s core values and shows great integrity, accountability, and professionalism in all interactions. Aids in furthering SCES’s mission and commitment to an inclusive environment.
- High School diploma with at least 1 year of related work experience required. Experience working with older adults and/or persons with disabilities who are transitioning from an institutional to a community setting strongly preferred.
- Has knowledge of community resources, programs, and benefits to help support an individual’s transition from an institutional to a community setting. Has a strong desire and willingness to continue learning and growing their knowledge base.
- Possesses knowledge of or the ability to learn systems and requirements for various older adults/disability services, benefits, and/or housing.
- Has the ability to initiate and sustain collaborative partnerships with internal and external stakeholders and work as part of an interdisciplinary team.
- Must have strong written and verbal communication skills.
- Comfortability working closely with providers, residents, and/or families with diverse cultural, linguistic, and socioeconomic backgrounds.
- Possesses strong organizational and time management skills including the ability to manage multiple projects and assignments in accordance with compliance and program/agency regulations, policies, and procedures.
- Proficient computer skills (Adobe MSWord, PowerPoint, Excel, SharePoint and other Microsoft 365 platforms and internet) required; experience with Wellsky and/or PASRR a plus.
- Ability to create and maintain program spreadsheets strongly preferred.
- Must meet both CORI/SORI and public health screening requirements.
- Must be able to travel to the office, clients’ homes, local community agencies, and area hospital and SNFs via public transportation or by car. Hybrid office/work from home schedule opportunities available.
- Must be accessible by phone and email during normal business hours.
- Bilingual preferred.
- Physical surroundings are comfortable with minimal exposure to injury or hazards.
- Occasional stress due to periodic or cyclical workload pressures and deadlines. Some interruptions involved.
- Frequently sits, stands, walks, bends, reaches, and stoops throughout the day.
- Frequently lifts, pulls, pushes, and carries up to 20 lbs.
- Periodic eye strain and light ear strain.