Transitional Care Coordinator

Responsibilities

• Coordinate with the interdisciplinary team and other departments in the provision of social services and discharge planning.
• Complete comprehensive psychosocial assessments of patients within the appropriate timeframe.
• Act as a liaison between patients, their families, internal departments, and community referral partners throughout the patient's stay in Short-Term Rehabilitation and Long-Term Care.
• Assist patients and families in accessing concrete services and resources.
• Demonstrate knowledge of and ability to utilize community resources effectively.
• Respond to crisis situations involving patients, families, and staff with guidance from supervisors.
• Facilitate individual counseling for patients and families as needed.
• Participate in the development of patient care plans and establish appropriate goals and treatment interventions for social services.
• Encourage residents and responsible parties to participate in care planning and attend care plan meetings.
• Maintain accurate and timely documentation in compliance with federal and state regulations and Jewish Home policies, including but not limited to Initial Assessments, Psychosocial/Mental Status Assessments, Care Plans, Social Service Progress Notes, and Discharge Planning documentation.
• Maintain confidentiality of all patient and facility information.
• Serve as a patient advocate and ensure patients are informed of their rights, responsibilities, and insurance benefits, as well as any changes that may affect them.
• Perform other duties as assigned by the Director of Social Services.
• JOB DETAILS
• Pay Rate: $28 - $35 per hour
• Hours: Full-Time, 40 hours per week
• Shift Schedule: 8:00 AM - 5:00 PM
• Days Off: Saturday and Sunday
• Working Days: Monday through Friday
• REQUIRED QUALIFICATIONS
• Bachelor's degree in Social Work or a related human services field, including but not limited to sociology, gerontology, rehabilitation counseling, or psychology.
• Minimum of one (1) year of supervised social work experience in a healthcare setting working directly with individuals.
• Minimum of one (1) year of experience with case management and discharge planning.
• Strong interpersonal skills and ability to work collaboratively as part of an interdisciplinary team.
• Ability to communicate effectively with patients, families, and staff at all levels of the organization.
• Effective time management skills with the ability to organize and prioritize workload.
• Understanding of Medicare and Medi-Cal guidelines.
• Knowledge of medical terminology preferred.
• PHYSICAL REQUIREMENTS
• Ability to lift, push, or pull a minimum of fifteen (15) pounds.
• Ability to exert muscle force to lift, push, pull, or carry objects.
• Ability to use abdominal and lower back muscles over time without fatigue.
• Ability to stand and/or sit for extended periods.
• Ability to bend, stoop, stretch, twist, sit, and reach.
• Fine motor skills and good visual and auditory acuity.
• Ability to maintain composure in stressful situations and work effectively under pressure.
• Ability to interact tactfully with residents, families, staff, visitors, gov

Benefits

Additional Information

Nestled in San Francisco's Excelsior neighborhood on a nine-acre campus, the San Francisco Campus for Jewish Living (SFCJL) is the leading senior services organization in Northern California. Our continuum of care includes: the Frank Residences assisted living and memory care; the Jewish Home and Rehabilitation Center, offering long-term skilled nursing, short-term rehabilitation, an acute geriatric psychiatric unit for adults over the age of 65; and our Foundation. Founded in 1871 and formerly known as the Jewish Home, our legacy grounds us as our vision propels us forward. Today, we've evolved to support more than 2,500 older adults each year through innovative, comprehensive programs rooted in the Jewish values of compassion, community, and excellence. We are equally proud of our inclusive culture, where 950 team members of diverse faiths and backgrounds work together in shared purpose.

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