Diversion & Transition Case Manager

Job Descriptions :

We look for skilled employees who are passionate about our mission and values, and providing excellent customer service.

We value our employees and the people we serve and it shows!

Our mission is to promote dignity, independence and health : honor choice & empower people.

Our Values are Service, Compassion, Integrity, Professionalism

Recruitment # : 379-10-25

Closes : November 21, 2025 (Externally)

Location : Salem, OR

Salary Range : Starting at $4,986 per month, with excellent benefits (see below),

Excellent Benefits : Medical / Dental 100% paid for employee and 90-98% for dependents, generous Paid-time off, Public Employee Retirement (PERS), Employee Assistance Plan, Long Term Disability, great culture.

General Description

Performs Professional-level work in the provision of social services by helping consumers and / or families to prevent unnecessary placement in nursing facilities and facilitate transitions for those who can be better served in a lower level of care, such as in-home or a community-based setting.

Essential Functions

Determine the need and appropriateness of Diversion and Transition Services

Develop transition plan

Implement, monitor and adjust transition plan

Transition case to ongoing Case Manager

Support and promote Diversion and Transition services

Promote Agency services and Aging and Disability Resources Connection (ADRC) concept

Facilitate confidence in Diversion and Transition Case Manager, and therefore the Agency and programs

Protect consumers and reduce Agency risk

Provide excellent customer service in a professional manner

• Determine the need and appropriateness of Diversion and Transition Services

Conduct consumer assessments to identify need and determine eligibility for services

Carry Nursing Facility caseload to better transition consumers to lower level of care as appropriate

Work directly with hospitals on new referrals for long term care services eligibility and placement

Gather information through interviews, observations, other staff, hospital discharge planners, and other resources

Consider consumer’s preferences, goals, safety, resources, etc. in determining Assessments and placements

Complete assessment tool

Assist consumers in Long Term Care Facilities which are closing and no longer operate under Medicaid to find alternate care

Carry enhanced care facility cases and manage the complexities of them

Carry specific need contract cases and manage the complexities of them

Analyze information gathered during assessment.

Determine the type of services necessary and the best type of in-home or community-based setting

Work with the consumer and / or family to accept plan developed

Coordinate the delivery of services identified

Arrange care setting, medical supplies, equipment, transportation, etc.

Provide assistance to alleviate serious environmental, medical, or social problems

Work with other partners to assist in effective transition

Evaluate the meeting of consumer needs through required monitoring for 30-90 days on case transfers and specialized contracts placements. This will include monitoring by phone, and in-person contact.

Evaluate delivery and quality of services

Facilitate provider payment

Adjust plan according to changing care needs of consumer, handling issues as they arise

Track work in Diversion and Transition database

Determine success and stability of transition plan

Identify the appropriate receiving Case Manager

Provide case management information through case notes / files

Communicate with all individuals involved to ensure a smooth transition

Communicate with appropriate staff and partners

Provide education and outreach on Diversion and Transition services for Agency staff, community partners, and the public

Educate self of Agency programs and services and other resources available for populations served, including using ADRC of Oregon online resource directory

Understand current issues and solutions for seniors and people with disabilities

Establish cooperative relationships with other human service agencies and organizations

Embrace and exhibit the Agency Mission, Vision, and Core Values

Use a person-centered approach

Provide excellent customer service

Meet the needs of consumers

Follow through and meeting deadlines

Interact with others in a respectful and culturally appropriate way

Work effectively with a wide variety of individuals

Maintain skills and knowledge to perform duties

Provide suggestions for improvement

Follow policies, regulations and requirements of project and Agency; document plan and progress as required.

Provide documentation as set forth by Federal, State, funding regulations, and Agency policy

Serve as a Mandatory Reporter of suspected abuse of vulnerable populations as required by policy and regulation

Maintain and sharing information according to privacy regulations

Apply the required knowledge and skills and exhibit critical thinking and problem solving

Exhibit good decision making, problem solving and work habits

Meet quality standards in accuracy, judgment, timeliness and following policy and procedure

Exhibit good work habits, including organizational skills, regular attendance, working independently, seeking and offering assistance when needed

Follow policies and procedures

Work independently, but seek and offer assistance when needed

Exhibit technology skills related to the work needing to be done, (word processing, spreadsheets, database, internet research, mail, IM, phones, copiers, assessment programs like as CAPS, Oregon ACCESS, etc.)

Exhibit a positive attitude towards consumers, co-workers and others

Job-specificskills and knowledge

Experience working with seniors and people with disabilities and the issues experienced by these populations (social, physical, care, etc.)

Knowledge of transition techniques, services, resources available, and service eligibility requirements

Knowledge of the Case Manager position, processes and responsibilities

Ability to interview others, observe, and assess situations accurately

Knowledge of family dynamics

Ability to translate observations and assessments to care plan

Knowledge of long term care settings and appropriateness for consumer needs

Knowledge of federal and state laws and regulations regarding long term care placements

Knowledge of components of services, supplies, equipment, and transportation to ensure services are appropriate to meet needs and delivered effectively

Ability to respond to issues and problem solve solutions

Knowledge of and experience with case management and case management assessment tools

Ability to learn specific tools used by Agency

Ability to explain services and concepts in easily understood terms

Ability to develop community relationships

Ability to identify outreach opportunities

Presentation skills and experience

Understanding of ADRC

Ability to source information regarding available services

Ability to build relationships and network

Ability to be a self-starter and be adaptable to change

Ability to be a team-player

Ability to set goals based on Agency expectations and develop a plan to meet and / or exceed goal expectations

Continuous learning about issues and solutions for populations served

Ability to learn and apply policies, regulations, requirements, rules around mandatory reporting, privacy, and confidentiality

Knowledge of Family Caregiver Support Program, and general knowledge of the dynamics of care giving and resources available

General Skills Needed to Meet Agency Expectations

Must be able and willing to perform the following :

Support the agency mission and exemplify its core values—integrity, professionalism, service, and compassion

Serve as a mandatory reporter of suspected cases of neglect, exploitation, and abuse of vulnerable populations as required by policy and regulation, and make the appropriate referral to a responsible agency such as Child or Adult Protective Services Units

Interact and work effectively with others in a team to deliver services to consumers

Demonstrate good interpersonal communication skills through written, verbal, and nonverbal communication

Use sound organizational skills to meet deadlines in a timely, accurate, and efficient manner

Speak, read, write, and understand English and follow verbal and written instruction

Perform other work as assigned by the supervisor

Required Experience :

Minimum Qualifications - Experience and Education

A qualified applicant will have a minimum of six (6) years of equivalent combination of education and / or experience which demonstrates the knowledge, skills and abilities required. The following qualifications meeting the minimum requirements will be considered :

Bachelors degree in social sciences or any related field

Work or volunteer experience working directly with consumers in social service type settings. Experience can be substituted for education.

Any combination of related education and relevant work experience equaling at least 6 years.

(For Bilingual positions only)

While not required, experience working with seniors or adults with disabilities or vulnerable populations is a plus.

Work Environment and Physical Demands

Case managers work both in an office environment and in the community. They :

Use a computer, telephone, and other office equipment

Need to tolerate and be able to work where the noise level is that of a typical office

Travel to consumers’ homes or care settings to meet with consumers (in an agency or personal vehicle)

Work on site at a social services entity and health care facility

May encounter frequent interruptions throughout the work day

Are regularly required to sit, talk, or hear

Use repetitive hand motions

Must be able to handle objects and sustain a sense of touch

Must be able to stand, walk, reach, and bend

Must be able to lift up to 20 pounds

Contact with the public in homes, facilities, or office environments may risk exposure to people with contagious diseases or irrational / hostile behavior and contact with domestic animals.

The physical demands are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Other Requirements

To be successful, candidates must :

Secure and maintain a valid Oregon driver’s license or have an acceptable alternative means of transportation

Attend work regularly to meet the demands of this job and to provide necessary services

Complete and pass a criminal background check

Supervisory Responsibilities

None.

Classification : Diversion and Transition Case Manager

Position Number : 379

Salary Range : R22

FLSA Status : Non-exempt

Unit : Diversion and Transition

Location : Salem

Reports to : RN Program Manager

Union Status : Represented

Last revision : March 9, 2023

This job description is a general guide for the job to be performed and does not cover everything. Employees may be required to perform other duties, including covering for, and in, other offices. Employees are expected to follow and perform other job-related duties requested by their manager.

Reasonable accommodations will be made as needed.

Job descriptions are subject to change.

Keyword : Diversion & Transition Case Manager

From : NorthWest Senior & Disability Services