About us

JASA is the go-to agency serving older adults in New York City, providing critical services to over 40,000 people annually. Founded 50+ years ago, JASA is a leading expert and innovator in aging services that recognizes the diversity among the aging population and honors older adults as vital members of society.

JASA’s life-changing support services, interventions and partnerships promote aging with a purpose and provide autonomy for older adults to remain in their homes and communities. JASA operates ten affordable housing properties, is a licensed home care agency and offers a breadth of integrative services citywide spanning free legal services, health and mental health services, home- delivered meals, social programming at senior centers and community trainings on elder abuse, peer health support, caregiver assistance and more.

- Upcoming position -

DUTIES AND RESPONSIBILITIES:

JASA’s Care Transitions Specialist (CTS) will coordinate, screen and facilitate the provision of home and community based support services to improve hospital to home care transitions to avoid preventable 30-day readmissions and other preventable hospitalizations. The CTS, an International Medical Graduate, must be bilingual (English/Chinese) and have the capacity to work across home, community and clinical settings.

The Care Transitions Specialist will conduct in-home assessments with the following objectives:

• Develop community-based service plan
• Identify home-based issues that may be linked to readmission risk
• Provide direct services and referrals to support stable home based functioning, focusing on:
• Medication/DME (other supplies): Ensure patient has medication, supplies and equipment and understands prescribed use
• Patient Education: Ensure patient is aware of their health conditions and how to manage them, and understands red flags and health risks
• Health Care Provider Communication and Coordination: Ensure patient has a primary care provider (PCP), update PCP on patient status, assist patients with follow up appointments
• Screen for and identify social and mental health needs of patients and provide closed-loop referrals

This position will be responsible for:

• The provision In-Home and In-Office Assessment of the social and emotional needs of the older adult client and their family, utilizing prescribed standardized assessment instruments; securing where appropriate the assistance of other social work and/or other professional consultants.
• The development and implementation of a case plan for the provision of the full range of social services for the older adult client(s) and family, including:
• Education and support to improve disease self-management and prevent avoidable hospital use
• Screening of client eligibility, application for, and advocacy in securing benefits and entitlements
• The arrangement for direct provision of services such as transportation, homecare services, meals on wheels, public assistance, Medicare, Medicaid, emergency cash relief, legal aid, protective services, vocational placement, medical and psychiatric examination and therapy, housing, etc.
• Referral, development of relationships and cooperative work with other community agencies, to meet the needs of clients
• Informing supervisors of situations of crisis or circumstances where the worker requires further guidance.
• Participating in training and team meetings.
• Collecting and inputting patient data into JASA’s Electronic Health Record system and assisting with analytics, reports and statistics, utilizing computers.
• Performs such other duties as assigned.

QUALIFICATIONS:

• International Medical Graduate or equivalent.
• Good writing/record keeping skills.
• Ability to read, write, speak, understand English.
• Ability to read, write, speak, understand Chinese.
• Must be computer literate, including ability to learn and use program-specific software.
• Ability to travel to clients' homes using mass transit and to negotiate any steps and barriers in clients' residences.
• Hospital discharge planning or other health care experience preferred.
• Understanding and appreciation of the roles of race, religion, ethnicity, sexual preference, and individual values as they relate to serving clients and families.

Job Type: Full-time

Pay: $52,000.00 per year

Benefits:

• Health insurance
• Paid time off

Schedule:

• Monday to Friday

COVID-19 considerations:
The Care Transitions Specialist should provide one-time verification of Covid-19 vaccination

Education:

• Master's (Required)

Experience:

• EMR systems: 1 year (Preferred)

Language:

• Chinese (Required)

Work Location: In person

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