Independent Living Systems, LLC
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Coordinator, Care Transitions
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Independent Living Systems, LLC
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About Us Join us in making a career in Independent Living Systems, an industry leader in managing home and community-based programs for over 20 years. Independent Living Systems, LLC and its subsidiaries offer a comprehensive range of clinical and third-party administrative services to managed care organizations and providers that serve high-cost, complex member populations in the Medicare, Medicaid, and Dual-Eligible Market. ILS provides tailored integrated solutions aimed at improving health outcomes while rebalancing costs, addressing social determinants of health and connecting members with community-based resources.
Position Summary The Transition of Care Coordinator is responsible for identifying and assisting Skilled Nursing Facility (SNF) enrollees who are potential candidates for transitioning into a community setting. The Coordinator collaborates with SNF staff, care managers, enrollees, and families to ensure proper care and a safe transition. The role also involves monitoring community enrollees receiving short-term rehab services in the SNF to ensure safe transition back to the community and prevent reverse transitions. This includes assessing enrollees’ needs and developing strategies to overcome barriers.
Essential Functions
Collaborate with SNF care managers to facilitate transition activities, including educating enrollees and families about available assistance.
Identify potential Nursing Home Transitions (NHT).
Assess enrollees' functional and medical needs.
Identify and evaluate appropriate community settings for safety.
Ensure LTC services are in place upon discharge.
Coordinate with SNF staff to ensure discharge includes Medicare-covered services.
Conduct weekly follow-ups on enrollees receiving rehabilitative services in SNF to plan safe community transition.
Establish partnerships with community providers.
Participate in weekly interdisciplinary care team meetings to review NHTs and discharge plans.
Achieve monthly Nursing Home Transition goals.
Education and Experience
Bachelor’s Degree in Social Work, Sociology, Psychology, Gerontology, or related field.
Master’s Degree (preferred).
Registered Nurse license in Florida (preferred).
Experience in Long-Term Care (preferred).
Proficiency in Microsoft Office applications.
Knowledge of Medicare and Medicaid.
Understanding of Federal and State Medicaid regulations (preferred).
Bilingual Spanish/English (a plus).
Required Skills
Excellent verbal and written communication skills.
Ability to motivate and work effectively with teams.
Strong organizational and planning skills.
Problem-solving and decision-making abilities.
Physical Demands Occasional standing, walking, sitting, using hands, reaching, talking, and hearing. Ability to lift up to 10 pounds. Specific vision requirements include close, distance, color, peripheral, depth perception, and focus. Must work well in a fast-paced environment.
Work Environment Moderate noise level. Accommodations available for disabilities.
Travel Up to 70% local travel required.
EEO Statement Committed to providing a safe, inclusive, and drug-free workplace. Equal employment opportunity regardless of race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, or other protected characteristics. Reasonable accommodations available.
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Coordinator, Care Transitions
role at
Independent Living Systems, LLC
Get AI-powered advice on this job and more exclusive features.
About Us Join us in making a career in Independent Living Systems, an industry leader in managing home and community-based programs for over 20 years. Independent Living Systems, LLC and its subsidiaries offer a comprehensive range of clinical and third-party administrative services to managed care organizations and providers that serve high-cost, complex member populations in the Medicare, Medicaid, and Dual-Eligible Market. ILS provides tailored integrated solutions aimed at improving health outcomes while rebalancing costs, addressing social determinants of health and connecting members with community-based resources.
Position Summary The Transition of Care Coordinator is responsible for identifying and assisting Skilled Nursing Facility (SNF) enrollees who are potential candidates for transitioning into a community setting. The Coordinator collaborates with SNF staff, care managers, enrollees, and families to ensure proper care and a safe transition. The role also involves monitoring community enrollees receiving short-term rehab services in the SNF to ensure safe transition back to the community and prevent reverse transitions. This includes assessing enrollees’ needs and developing strategies to overcome barriers.
Essential Functions
Collaborate with SNF care managers to facilitate transition activities, including educating enrollees and families about available assistance.
Identify potential Nursing Home Transitions (NHT).
Assess enrollees' functional and medical needs.
Identify and evaluate appropriate community settings for safety.
Ensure LTC services are in place upon discharge.
Coordinate with SNF staff to ensure discharge includes Medicare-covered services.
Conduct weekly follow-ups on enrollees receiving rehabilitative services in SNF to plan safe community transition.
Establish partnerships with community providers.
Participate in weekly interdisciplinary care team meetings to review NHTs and discharge plans.
Achieve monthly Nursing Home Transition goals.
Education and Experience
Bachelor’s Degree in Social Work, Sociology, Psychology, Gerontology, or related field.
Master’s Degree (preferred).
Registered Nurse license in Florida (preferred).
Experience in Long-Term Care (preferred).
Proficiency in Microsoft Office applications.
Knowledge of Medicare and Medicaid.
Understanding of Federal and State Medicaid regulations (preferred).
Bilingual Spanish/English (a plus).
Required Skills
Excellent verbal and written communication skills.
Ability to motivate and work effectively with teams.
Strong organizational and planning skills.
Problem-solving and decision-making abilities.
Physical Demands Occasional standing, walking, sitting, using hands, reaching, talking, and hearing. Ability to lift up to 10 pounds. Specific vision requirements include close, distance, color, peripheral, depth perception, and focus. Must work well in a fast-paced environment.
Work Environment Moderate noise level. Accommodations available for disabilities.
Travel Up to 70% local travel required.
EEO Statement Committed to providing a safe, inclusive, and drug-free workplace. Equal employment opportunity regardless of race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, or other protected characteristics. Reasonable accommodations available.
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