Senior Connections, the designated Area Agency on Aging for the City of Richmond and seven surrounding counties, is seeking a Full Time Care Transitions Coach. This is a hybrid position that requires talking directly to patients who have been recently discharged from the hospital to help them strategize an effective plan to avoid readmission and conducting home visits as needed. Interventions are focused on patient self-management of chronic diseases by teaching/modeling, self-advocacy and education including how to navigate complex health care systems, assuring that patients are alerted to supports and services available through Senior Connections and that needed community referrals are made using a computerized data base system. All documentation is done electronically.

Conducts in-person and telephonic visits that promote self-care management including encouraging patients to attend medical/therapy appointments, teaching patients to recognize symptoms, and coaching on how to take appropriate actions when needed. In-person visits may occur in the home. Prepares and maintains records and reports utilizing data management systems. Timely reporting of interactions in a database.

• Bachelor’s degree from an accredited college or university in gerontology, social work, nursing, or a related field. 
• Experience providing direct service/counseling to older adults and/or families is preferred. 
• Demonstrated experience with documentation of client interactions.
• Position requires organizational skills with ability to handle details and multiple priorities. 
• Effective communication skills. Advanced Experience with Microsoft Office. Proficient in Microsoft Excel. 
• Must have good computer skills and experience working with online databases. 
• Must have the ability to work independently and as part of a team. 
• Local travel and valid driver’s license required.