Transition Case Manager

Job Description Summary:

Job Description:

The Transitions Program was designed to work with individuals who are incarcerated and due to be released within 90 days with the intention of providing systematic assistance in the navigation of healthcare and social service systems. The goal of the program is to work with women in setting goals prior to release and to provide care coordination after release to avoid recidivism. The Transition Case Manager (TCM) is responsible for the overall support of the Transitions Program at CHCI including on-going communication with DOC, community partners and patients. The TCM will work directly with the Program Specialist Manager to support daily operations of the program and to ensure seamless entry into care for individuals eligible for services. The TCM will provide efficient data retrieval, documentation, analysis, and monitoring as needed to meet the deliverables required from the funder.

GENERAL RESPONSIBILITIES:

• Work with the Program Specialist Manager to develop policies, procedures, manuals, and trainings as needed for the Transitions Program.

• Assist the Program Specialist Manager with all aspects of compliance for all safety and regulatory requirements for funding.

• Complete and monitor data entry, record keeping, and reporting.  

• Complete documentation in CHC EHR daily that provides an overview of encounters and information pertinent to continuity of care and data tracking for each participant.

• Conduct and maintain community outreach and collaboration with community organizations and partnerships.

• Obtain and maintain WRNA Training and conduct WRNA Assessments as appropriate for participants. Additionally, use WRNA training to interpret results conducted pre-release and use them to assist participants in setting goals.

• Develop TCM schedules of patients including locations and services.

• Work with DOC discharge planners to assess patients being released and develop a comprehensive service plan with short and long term goals and objectives for each individual patient.

• Work with patients to use their individual service plan to accomplish tasks, activities, goals, and objectives that align with their own personal goals and their long term plan for success.

• Provide support to CHC providers to facilitate continuity of care, treatment adherence, and completion of healthcare goals as needed.

• Practice and educate on harm reduction model of care that will promote the accomplishment of small, manageable goals while also working with patients to empower long term plans that are reasonable and fit their needs.

• Assist with client enrollment and participation.

• Assist with template creation, scheduling, and follow up for all Transitions patients.

• Act as a patient advocate for individuals experiencing challenges that include social determinants of health like housing insecurity, food insecurity, and economic vulnerability.

• Coordinate patient care internally and externally to ensure the efficient accomplishment of healthcare and social goals.

• Actively participate in all meetings related to Transitions Program and CKP.

• Provide dissemination of information internally at CHC and externally at partner agencies and with community collaborators about services available and how to access them.

• Work with communications team to develop and update materials that provide information about the Transitions Program for any audience.

• Performs other related duties as assigned

III.       REQUIRED QUALIFICATIONS

• Associates Degree in Human Services or related field or high school diploma/GED and adequate experience to replace this.

• Valid Connecticut Driver’s License and ability to travel to locations across the state as needed.

• Prior experience working with community agencies and programs.

• Demonstrates ability to work cooperatively with providers and agencies.

• Effective oral and written communication skills.

• Prior experience in providing services to bicultural individuals/families desired.

• Ability to organize, prioritize, and maintain deadlines

• Working knowledge of the program, its target populations and additional resources available in the community.

• CHC requires as a condition of employment current American Red Cross CPR for the Professional Rescuer and AED (CPR/FPR/AED) certification. The only acceptable alternative is current American Heart Association BLS/AED for Healthcare Providers certification

This position requires some physical exertion, mostly in support of groups in a program area.  Work is both remote, office-based and community-based.

Full-Time, 40 hours a week with evenings and/or weekends required based on program needs. Ability to travel to locations as deemed necessary.

Organization Information:

The Moses/Weitzman Health System is a global leader addressing challenges faced by organizations caring for the poor and diverse populations, and is home to programs focusing on education, research, and process improvement support for safety net providers. The system delivers primary care to more than 150,000 patients in Connecticut, and extends access to specialty care for more than 2.5 million individuals across the U.S. It is a national accrediting body for organizations training advanced practice providers, and offers accredited education and training for Medical Assistants in multiple states. As an incubator for new ideas in areas including social justice, the environment, and social determinants of health, the MWHS is addressing challenges faced by providers caring for underserved communities, creating innovative and impactful initiatives led by nationally and internationally recognized experts. As it forges pathways into the future of primary care, the MWHS honors Lillian Reba Moses (1924-2012), a granddaughter of slaves, and Gerard (Gerry) Weitzman (1938-1999), whose ancestors escaped pogroms in Eastern Europe. Their vision and commitment to justice and equity in healthcare is the foundation upon which the Moses/Weitzman Health System was built.

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