Transition Specialist Jobs in Michigan

Area Agency on Aging of Northwest Michigan

Make a difference in the lives of older adults, caregivers and adults with disabilities! The Area Agency on Aging of Northwest Michigan seeks an energetic, highly organized, experienced community supports specialist.

The Area Agency on Aging of Northwest Michigan (AAANM) is the place to turn for assistance with complex issues facing older adults, adults with disabilities and caregivers. AAANM links to, coordinates with, and provides a variety of programs, services, and resources within the 10-county service area of northwest Michigan. AAANM is a nonprofit corporation operating as a designated Area Agency on Aging by the Michigan Department of Health and Human Services and is a Medicaid MI Choice Waiver agent.

Mission Statement: Our mission is to serve and advocate for older adults, persons with disabilities and caregivers by supporting their independence, dignity, and quality of life.

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The Care Transition Specialist (CTS) provides person-centered care transition coordination and support to older adults transitioning from hospitals and other medical care facilities back to their homes and communities. The CTS serves as a trusted liaison between participants, health care providers, community-based organizations, social service agencies, and other partners to improve access to services, support successful transitions of care, and reduce avoidable hospital and emergency department utilization.

The Transition Specialist provides proactive discharge planning, transition coaching, service coordination, participant education, and post-discharge follow-up. The position supports participants in identifying and addressing health-related and social needs that may affect their ability to safely remain in the community.

Job Type: Full-time, Hybrid

Schedule:

• Monday through Friday 8am to 4:30pm. Specific work schedule to be established with supervisor to ensure coverage for departmental or participant needs.
• Must live within the AAANM service area region.

Benefits:

• Health insurance
• Dental Insurance
• Vision Insurance
• Health savings account
• Life insurance
• Paid time off
• Tuition reimbursement
• 403(b) matching
• Flexible schedule

Essential Job Functions:

• Coordinate with hospitals and other medical care facilities to engage eligible participants prior to discharge whenever possible and support proactive discharge planning.
• Complete participant intake and initial assessment activities within required CTCS timeframes, including identification of health history, medications, providers, durable medical equipment needs, living arrangements, and other factors affecting a successful transition home.
• Utilize person-centered planning to identify participant goals, preferences, needs, barriers, and priorities and develop an individualized plan for transition and community support.
• Provide transition coaching and education to increase participants' health knowledge, self-sufficiency, and ability to navigate health and social service systems.
• Offer and refer participants to home- and community-based services, long-term services and supports, and other resources necessary to promote safe community living.
• Identify accessible housing and home safety needs and assist participants with accessing appropriate resources, supports, and durable medical equipment.
• Coordinate transportation to primary care and other medically necessary follow-up appointments, as necessary.
• Support medication management by helping participants understand their medication plan, identifying potential barriers or concerns, and facilitating medication review or consultation with an appropriate health care professional when needed.
• Assist participants with scheduling and completing primary care follow-up, with a goal of connection to the participant's primary care provider within seven days of discharge.
• Provide education regarding red-flag warning signs.
• Conduct ongoing post-discharge follow-up, including at least weekly participant contact/check-ins for a minimum of 30 days, to assess whether services have been implemented, identify new or unresolved needs, and address barriers to successful transition.
• Coordinate with internal programs, community organizations, health care providers, Michigan Hubs/Regional Health Collaboratives, and other cross-sector partners to facilitate referrals and improve communication across service systems.
• Maintain accurate, timely, and complete participant records and documentation in accordance with program, agency, and funding requirements.
• Attend organizational, team and other meetings as required or scheduled.
• Supports departmental and organizational efficiency, effectiveness, and impact to change for sustainability of the organization.
• Maintain HIPAA compliance and confidentiality at all times regarding participant and co-worker information per all agency guidelines.
• Continually seek and promote ways to improve process and procedures.
• Attend and participate in community meetings and workgroups as assigned by Supervisor.
• Ensure the responsibilities of the position are always handled in a safe and responsible manner.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

• High school diploma or equivalent required; associate's or bachelor's degree in human services, social work, public health, health care, aging services, or a related field preferred.
• Experience working in community health, aging services, health care, social services, care coordination, or a related setting preferred.
• Community Health Worker credential/certification. If not credentialed at hire, ability to obtain required credentialing within an agency-established timeframe.

Knowledge, Skills and Abilities Required

• Knowledge of community resources and aging services; health and social service systems; person-centered planning; health-related social needs; care transitions; and barriers affecting older adults living in rural communities.
• Establish and maintain productive communication and working relationships with individuals inside/outside the Agency including consumers, guardians, management, community partners, coworkers and support staff.
• Represent the Agency’s set of core beliefs and values.
• Ability to effectively use telehealth technology to conduct participant interviews, as needed and per HIPAA guidelines.
• Effective written and verbal communication skills to convey and receive information (in person, via telehealth, on the phone, or through e-mail correspondence) and accurately document all forms of communication in appropriate locations.
• Attention to detail.
• Use of judgement, management, and ability to delegate and utilize appropriate resources in the organization for conflict management.
• Use critical thinking, problem solving and knowledge of agency to appropriate address complex situations.
• Ability to show and maintain empathy and compassion.
• Excellent listening skills and ability to decipher individuals’ needs and concerns.
• Maintain knowledge of and information about community resources.
• Good organizational, analytical, and judgment skills to manage time, prioritize, work independently, and handle multiple tasks.
• Proficiency in Microsoft Office Suite or similar software and standard office equipment including computers, calculators, and telephones.

Certificates, Licenses, Registrations

• Community Health Worker certification
• Maintain all required trainings and certifications.
• Possess a valid US driver's license and maintain auto insurance.
• Proof of U.S. Citizenship or possession of necessary papers allowing holder to work legal in the United States

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

• Perform duties in an office setting where the noise level in the work environment is usually moderate.
• Use standard office equipment such as computers, phones, and photocopiers routinely.
• Hybrid work which may include on-site presence in the Agency office at 1609 Park Drive, Traverse City.
• May include being in a participant’s home, if required.
• Travel throughout region for in-home/hospital visits with program participants.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Sit at a desk and work on a computer for prolonged periods of time, walk/move around and stand, talk and hear and use hands to handle, control or feel objects, tools or controls.
• Lift up to 25 pounds.
• Use close vision and ability to focus on computer screens and documents; distance vision; peripheral vison; depth perception; color vision.
• Ability to drive within the 10-county region.

Equal Opportunity Employer (EOE):
Area Agency on Aging of Northwest Michigan provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type 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.

Job Type: Full-time

Benefits:

• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Work Location: Hybrid remote in Traverse City, MI 49686