Care Transitions Liaison Program (Ctlp) Case Manager

Full-time, 35 hours/week

NOT Remote

Responsible for functioning as a core member of the Interdisciplinary Discharge Planning Team (IDPT) composed of the Community Transitions LiaisonCase Manager and appropriate Skilled Nursing Facility (SNF) staff with the primary focus being to assess the need and eligibility of residents who have been admitted to a skilled nursing facility, for discharge potential and appropriateness for community services.

• As part of the CTLP team, the CM will visit each of the skilled nursing facilities (SNFs) in Greater Springfield Senior Services (GSSSI) catchment area on a weekly basis to attend regularly scheduled meetings with SNF SWs/ Discharge Planners as well as meet with residents.
• Perform on-site evaluation of residents aged 22+ admitted to a SNF.
• Participate in discussions regarding any consumer previously granted a Short-Term Clinical Eligibility Determination in order to monitor the consumer's progression toward discharge.
• Provide consultation and education of SNF staff and assist with discharge planning where appropriate.
• Educate SNF residents and their informal supports regarding service options and community alternatives.
• Attend family meetings as requested.
• Conduct outreach at SNFs to promote CTLP program.
• Complete client-oriented needs assessments which identify issues or problems which inhibit secure independent living at home.
• Assess a resident's functional, health and income status to determine eligibility and appropriateness for community long term care services or programs.
• Work with the member/applicant, formal and informal supports to develop a service plan which addresses the member/applicant's needs.
• Ensure that members/applicants have access to public benefits and other community services.
• Advocate and act as a resource in areas of interest and/or concern for elders.
• Ability to understand basic medical conditions and converse effectively with medical personnel.
• Good computer skills including working knowledge of spreadsheets, word processing and data entry (including Windows, Word, and Excel).
• Must be able to operate a keyboard 80-90% of the time.

Education and Experience

• Bachelor's Degree in Social Work, Human Services, Nursing or a related field
• Knowledge and experience working with elders and individuals with disabilities
• Knowledge of community based services (Mass Health, state agencies and various providers) for elders and persons with disabilities
• Minimum of one year experience transitioning individuals from nursing facilities or long-stay hospital to community based settings

Public Service Loan Forgiveness (PSLF)

If you are employed by a not-for-profit organization such as GSSSI, you may be eligible for the PSLF Program for student loans.