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POSITION:
    Care Transitions Coach
    Care Transitions Program

PAY GRADE:
    14

WAGE:
    $30,790 (as a minimum)

ESSENTIAL

FUNCTIONS:

Evaluates the potential and coordinates the transition of eligible Medicare hospital patients returning to the community to assist in prevention of re-admission to the hospital.
Performs initial hospital visit, home visit and three telephone calls to the patient encouraging them or their caregiver to assume a more active role in their care.
Work with the patient and/or caregiver on the four elements of the Care Transitions Intervention known as the four pillars of the program.
Plan and coordinate additional community-based services for which the patient may be eligible.
Develop a close working relationship with all hospitals involved in the program.
Provide necessary advocacy, support and training to patients transitioned from the hospital to the community.
Complete all required documentation and informational data, in a timely manner, as needed for reporting and accountability to appropriate agencies.
Attends and participates in meetings with all appropriate health and human service organizations.
Educates community organizations, hospitals and other health and human service agencies about the care transitions intervention process.
Adheres to all policies, laws, regulations and codes of ethics and confidentiality as outlined by federal and state laws, and agency policies and procedures.

QUALIFICATIONS:

Bachelor's Degree in Social Work or related field from an accredited college or university and two years care transitions experience preferred.
Must successfully obtain Criminal History Clearance from the PA State Police and Child Abuse Clearance from the PA Department of Welfare.
Demonstrated knowledge of medical terminology and health/social services available to the patient.
Demonstrated ability to make incisive observations, obtain vital information and make appropriate recommendations during patient/caregiver interviews and/or while reviewing records.
Ability to transport oneself, as necessary, in the performance of essential functions.
Ability to interpret detailed medical records and documentation obtained from health care providers.
Demonstrated ability to handle patients with chronic mental health conditions.
Ability to work independently following established policies and procedures.

QUALIFIED INDIVIDUALS MUST SUBMIT A LETTER OF INTEREST TO THE SOUTHWESTERN PENNSYLVANIA HUMAN SERVICES, INC., OFFICE OF HUMAN RESOURCES, 300 CHAMBER PLAZA, CHARLEROI, PA 15022-1607, ATTENTION: DEPARTMENT 1222, NO LATER THAN 5:00 P.M., THURSDAY MARCH 1, 2012.

EQUAL OPPORTUNITY EMPLOYER