Nursing Home Transition Coordinator (NHTC)- Bucks/Montgomery/Berks County

Company Overview

At the heart of our work is a meaningful mission: Enhancing Abilities and Changing Lives . Every day, we work closely with those we serve—helping individuals and their families navigate the complex healthcare landscape and understand the full spectrum of care options available. Our efforts are guided by a deep commitment to promoting dignity, independence, and a high quality of life for older adults, individuals with disabilities, and veterans.

Summary

We are seeking a Nursing Home Transition Coordinator (NHTC) to join our team. The NHTC collaborates with residents, families, case managers, and community resources to develop and implement person-centered transition plans that promote long-term independence and quality of life. The coordinator ensures transitions comply with Pennsylvania DHS Office of Long-Term Living (OLTL) regulations and the individual’s Managed Care Organization (MCO) requirements, while advocating for residents to exercise choice and achieve their desired quality of life.

The Nursing Home Transition Coordinator’s responsibilities are:

• Conduct outreach and education for nursing facility residents regarding Pennsylvania’s NHT process and community living options
• Complete NHT readiness assessments and assist participants in developing person-centered transition plans
• Coordinate with CHC Managed Care Organizations, Service Coordinators, nursing facilities, and community agencies
• Assist participants with locating safe, affordable, and accessible housing, including navigating Pennsylvania housing resources and subsidy programs
• Coordinate durable medical equipment, home modifications, transportation, and in-home supports prior to discharge
• Support participants in applying for benefits and accessing community resources (e.g., LIHEAP, SNAP, waiver programs)
• Provide advocacy to ensure participant choice, independence, and safety
• Maintain accurate documentation in alignment with PA DHS and CHC requirements
• Travel frequently within assigned counties to conduct visits and support transitions.

Position Requirements:

Must have a bachelor’s degree in social work, psychology or other related fields with practicum experience OR in lieu of a bachelor’s degree, must have at least three (3) years’ case management experience in a social service or healthcare-related setting.

Start your journey. If you're driven to make a meaningful impact on the lives of individuals with disabilities and older adults, we encourage you to apply and become a valued member of our committed team at UDS Foundation.

UDS Foundation offers:

• Career advancement opportunities
• Remote working
• Phenomenal healthcare benefits and safety and wellness programs
• An environment that supports and promotes diverse backgrounds and viewpoints
• Lucrative paid time off, including short- and long-term disability coverage
• Highly competitive compensation package
• Retirement account
• Continuing education reimbursement program

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran.