Join the exciting world of Integrated Transitional Care! As an Integrated Transitional Care Specialists, guided by our supervisor, you’ll play a key role in transitioning Members from acute care or skilled nursing facilities back to the community. This Bilingual (English/Spanish) position ensures language proficiency and offers dynamic responsibilities, from identifying suitable transitions to collaboration with the Transitions of the Care Team. Dive into the community engagement, working closely with the Members and family and collaborating across various departments for safe transitions.

Key Responsibilities:

1. Assist the Nurse or Social worker in identifying Members who are appropriate to transition back to the community. 
2. Perform facility site visits to communicate with Member and/or family members health plan benefits, available community resources, and Members goals for transition, if appropriate.
3. Working closely with the Transitions of Care Team to develop a safe discharge plan for Member’s transition back to the community.
4. Work with Members and family members to identify needs and appropriate resources, help navigate the system and provide guidance for a successful transition back to the community.
5. Communicate with Providers regarding Members follow-up visits, community resources, and other matters pertinent to the Members transition ack to the community.
6. Collaborate with other departments such as Community Health, Care Management, Behavioral Health, Independent Living and Diversity Services, to assist in the safe transitions.
7. Maintain appropriate documentation in the medical management system.
8. Participate in multidisciplinary team meetings, e.g., interdisciplinary care conferences, Housing team meetings, educational rounds and other meetings as required.

Education & Requirements  

• Bilingual (English/Spanish) - written and verbal skills required


• Minimum of three (3) years of experience of performing or facilitating social work or related services in a community-based setting


• Bachelor’s degree required in social work or a related field from an accredited institution required

Key Qualifications

• Knowledge of community resources. Knowledge of Medicare and Medi-Cal benefits and eligibility criteria


• Skillful at offering information and education to Members and their families


• Maintain strong working relationship with all internal departments to facilitate interdepartmental communication and coordination as needed