Transition Specialist - SHARE Military Initiative at Shepherd Center in Atlanta, Georgia

Job Description:

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.


• Demonstrates involvement in program development.


• Provide education, guidance, and support post discharge, with a strong focus on medical, financial and psychosocial needs.


• Completes thorough and accurate documentation in electronic records.


• Coordinates language services when interpretation needs arise in the clinic.


• Understand ethical considerations, patient in crisis in relations to finances, neglect, abuse, psychosocial needs, etc.


• Maintains knowledge of current relevant state and federal regulations, Joint Commission standards and criteria, and documentation requirements.


• Performs other responsibilities as required.


• Practices proper safety techniques in accordance with Center and departmental policies and procedures. Responsible for the reporting of employee/patient/visitor injuries or accidents, or other safety issues to the supervisor and in the occurrence notification system.


• Monitors and ensures compliance with all regulatory requirements, organizational standards, and policies and procedures related to area of responsibility. Identifies potential risk areas within area of responsibility and supports problem resolution process.

• Clinical degree in Allied Health or eligible to sit for the CCM/CMC.

• 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.

• Minimum of two (2) years broad clinical experience.

• Effective time management skills.


• Excellent communication skills, both verbal and written.


• Effective decision making/problem-solving skills and creativity in problem solving.


• Demonstrated effective critical thinking skills and ability to anticipate patient discharge needs.


• Understanding of the interdisciplinary team approach and rehabilitation environment.


• Moderate to expert computer skills.


• Working knowledge of financial aspects of third-party payors and reimbursement

• Experience in care coordination, case management, discharge planning and utilization review preferred.

• Uses body, tools, or special devices to safely, effectively, and efficiently to move, guide, or place patients. Involves some latitude for judgement with regard to precision attained and the selection of what adaptive device(s) to utilize.


• Ability to transfer and position patients, consistent with lifting up to 50 lbs.

• Some potential for exposure to blood and body fluids.