Transitions Coordinator

POSITION SUMMARY: Implement and build community awareness of the Transitions Program for the ClearPath Healthcare service area. Coordinate / case-manage client needs and volunteer services. Make referrals to appropriate community services as needed by the client/ family in a timely manner. Interact with Transitions clients and families, Executive Director, Marketing Coordinator, Volunteer Coordinator, volunteers, physicians’ staff, community agencies/ services, and the general public.

DUTIES:

• Provide one-on-one non-medical and case management support to individuals through themental, physical, and emotional changes that may accompany life-limiting illness.
• Process and perform client intakes / admissions as required. Gather information pertinent to client health care and provide family information regarding community resources.
• Work closely with clients in developing and achieving their personal health goals to enhance quality of life.
• Assist clients in navigating the healthcare systems, including scheduling appointments and accessing community services and resources.
• Advocate for clients' needs and ensure equitable access to healthcare services, community resources, and support programs.
• Conduct and document a minimum of one face-to-face visit per month with each assigned client to assess needs, monitor progress toward goals, provide ongoing support, and identify changes requiring intervention or care plan updates.
• Communicate with primary care and specialty providers regularly, keeping them informed of client health changes and concerns, as well as services provided, obtaining their approval when appropriate.
• Educate and provide information on health topics such as nutrition, physical activity, disease prevention, chronic disease management, and end of life care.
• Organize and facilitate workshops, health fairs, and informational sessions to enhance community awareness supporting and working alongside our Community Engagement Manager.
• Maintain accurate, timely, and complete chart documentation, ensuring all client visits, communications, care coordination activities, and services are charted daily in accordance with organizational requirements.
• Maintain monthly statistical reports, tracking referrals.

• Maintain regular and professional communication with supervisors and team members to support coordination of services, continuity of care, and organizational goals.
• Maintain confidentiality of client information, adhering to HIPAA policy.
• Basic ability to work with ill & dying clients with respect to their individuality, values and lifestyle. Speaking with clients and providing education on end-of-life care and supporting their goals.
• Demonstrates ability to prioritize under pressure.
• Other duties as required

QUALIFICATIONS:

• Self-directed with strong time management skills and the ability to work independently with minimal supervision.

• Excel in written and oral communications, including letter correspondence, ad creation, social media communications, and public speaking.

• Demonstrate strong interpersonal and communication skills, maintaining effective communication with clients, families, and community partners.

• Ability to work in multiple disciplines and with various individuals.

• Ability to successfully use a variety of computer applications.

• Familiarity with Central Oregon resources related to client advocacy.

• Valid Oregon driver’s license and access to adequate transportation to carry out functions

OSHA CATEGORY:

III: Tasks that involve no exposure to blood, body fluids or tissues