Care Transition Specialist

ABOUT US Join Independent Living Systems, an industry leader in managing home and community-based programs for over 20 years. We specialize in offering comprehensive clinical and third-party administrative services to managed care organizations and providers serving high-cost, complex member populations in the Medicare, Medicaid, and Dual-Eligible Market. Our tailored integrated solutions aim to improve health outcomes while balancing costs, addressing social determinants of health, and connecting members with valuable community resources. Position Summary As a Care Transition Specialist, you will be pivotal in facilitating the seamless transition of Skilled Nursing Facility (SNF) enrollees into community settings. Collaborating with SNF staff, care managers, enrollees, and families will be essential in coordinating care and ensuring successful, safe transitions. You will also monitor community enrollees receiving rehabilitation services in the SNF to prevent reverse transitions. This role necessitates assessing enrollees' interests and needs while developing innovative strategies to overcome barriers to successful transitions. Essential Functions Partner with SNF care managers to facilitate transition activities effectively. Educate enrollees and families about the transition program and support options available. Identify candidates suitable for Nursing Home Transitions (NHT). Assess enrollees' functional and medical needs to tailor support. Determine appropriate community settings for successful transitions. Evaluate the safety and suitability of community settings. Ensure that long-term care services are established before discharge. Collaborate with SNF staff to guarantee enrollees are discharged with necessary Medicare services. Conduct weekly follow-ups on enrollees receiving rehabilitation services to plan safe transitions back to community settings. Develop strong partnerships with community providers to enhance resources. Participate in interdisciplinary care team meetings to review potential NHTs and current enrollees' discharge plans. Achieve monthly goals for Nursing Home Transitions. Education and Experience Bachelor's Degree in Social Work, Sociology, Psychology, Gerontology, or a related field. Master's Degree is preferred but not required. Registered Nurse, licensed in the State of Florida, is preferred but not required. Experience in Long-Term Care Programs is preferred but not required. Proficiency in Microsoft Office applications. Knowledge of Medicare and Medicaid systems is essential. Familiarity with Federal and State Medicaid Managed Care regulations is highly preferred. Bilingual in Spanish/English is a valuable asset. Required Skills Excellent verbal communication skills to convey information clearly and influence others. Strong written communication skills to effectively document and extract information from materials. Able to work collaboratively and inspire others to meet objectives. Highly organized with the ability to prioritize tasks and develop action plans to achieve goals. Robust decision-making and problem-solving abilities, including systematic approaches to identify and implement effective solutions. Physical Demands This job requires occasional standing, walking, and sitting, along with the use of hands. Ability to lift/move up to 10 pounds is necessary. Specific vision abilities include close and distant vision and depth perception. This role involves working in a fast-paced environment. Work Environment The work environment is typically moderate in noise level. Reasonable accommodations can be made for individuals with disabilities. Drug-Free Workplace In compliance with the Drug-Free Workplace Act, we strive to provide a safe working environment. Our policy aims to eliminate drug and alcohol use in the workplace. Travel This position requires up to 70% travel, primarily local. EEO STATEMENT We provide equal employment opportunities regardless of race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, ancestry, or any other characteristic protected by law.

Created: 2026-03-04