Transition Specialist - SHARE Military Initiative - Shepherd Center

Shepherd Center, located in Atlanta, Georgia, is a private, not-for-profit hospital specializing in medical treatment, research and rehabilitation for people with spinal cord injury, brain injury, stroke, multiple sclerosis, spine and chronic pain, and other neuromuscular conditions.

Join us in our mission to help people with a temporary or permanent disability, rebuild their lives with hope, independence and dignity, advocating for their full inclusion in all aspects of community life.

At Shepherd Center, you'll discover a diverse and inclusive environment, enlightened leadership, a culture of teamwork, professionalism and mutual respect. If you are seeking career advancement, continuing education opportunities coupled with a welcoming and fun workplace, competitive compensation and employment benefits, visit our careers page to explore current openings.

The (SHARE) Transition Specialist provides post-discharge case management as well as telephonic and in-home visits for SHARE clients through implementation of the transition plan developed by the comprehensive rehabilitation team members (including occupational therapists, physical therapists, therapeutic recreation specialists, speech therapists, psychologists, and job placement staff). The Transition Specialist creates and implements treatment plan to assist achievement of collaborative goals established by client, caregivers, and treatment team; evaluates client progress; facilitates relationships and support between client and community; and provides feedback to treatment team regarding effectiveness of treatment strategies. This role also provides guidance and assistance to clients as appropriate in advocating for client needs related to veteran benefits, disability claims, external provider appointments.
Required Minimum Education -
Clinical degree in Allied Health or eligible to sit for the CCM/CMC.

Required Minimum Certification
Certification in Case Management (Case Management Society of America, American Case Management Association, American Nurses Credentialing Center, or equivalent certification within two years of position start date.

Licensed to practice in the state of Georgia (PT, OT, SLP, Licensed Social Worker or Certified Recreational Therapist.

Required Minimum Experience

Minimum of two (2) years broad clinical experience.

Job Responsibilities:

• Assesses individual patient rehabilitation needs, meets with and assists client and family identify discharge and community re-entry goals.
• Develops and periodically assesses, adapting as needed, treatment plan with client and family designed to meet client, family, and community support potential, including introducing community programs and other resources and information pertinent to program.
• Collaborates with treatment/service team, internal and external case managers and interdisciplinary team on client clinical, medical, social needs pertinent to quality of care and transition from therapy to home community.
• Assists client and family identify community resources that will maximize health, safety, and wellness.
• Provides guidance and supports client life skills services/wellness plan to increase independence to include home safety, activities of daily living, and community participation.
• Facilitates, implements, and coordinates services, such as scheduling calls and conferences, training, home visits, provider appointments, and support resources.
• Coordinates needs for goal attainment and status, funding, home modifications, DME procurement, and other matters related to client care.
• Creates and executes discharge plan; clarifies/identifies funding resources as needed.
• Provides post discharge education and planning, and coordinates community planning and peer support resources, educating and guiding client and/or family on equipment access, supply vendors, service organizations and resources, healthcare follow up and maintenance, medication management, safety, and personal management activities.
• Completes all documentation regarding treatment plan, care plans, client and family communications and interactions, letters and forms thoroughly and efficiently.
• Identifies ethical dilemmas and resolves such dilemmas reasonably through appropriate consultation and moral action, notifies supervisor when ability to provide services is compromised.
• Maintains current knowledge and understanding of benefits and benefits administration.
• Maintains professional competence, including licenses and/or certifications.
• Follows through on any patient/client/family grievances.
• Attends and contributes to staff and group meetings.
• Serves on a departmental committee.
• Serves on a hospital-wide committee.
• Demonstrate