Nursing Home Transition (NHT Coordinator)/Human Services

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WHO IS Alleghenies United Cerebral Palsy (AUCP)- AUCP is a non-profit organization founded in 1955. It started as a grassroots effort by a group of concerned parents who wanted to find support for family members aged 18 – 59 with physical and intellectual disabilities. Starting in a church basement, we have evolved into an organization serving over 4,000 lives 18 and older, with staff throughout PA. Our mission is to assist individuals with disabilities in meeting their basic needs, enhancing their quality of life, and promoting their independence while also allowing them to be active participants in the decision-making and direction of their services.

Work Location: Hybrid/Remote Position with the ability to complete visits in the community in PA. Must live in PA or be willing to travel to PA to complete home visits.

Work Environment Requirements:
This is a hybrid position requiring both in-office and remote work. When working remotely, employees must maintain reliable high-speed internet access to ensure consistent connectivity for meetings, systems, and communication. Failure to maintain adequate internet service may impact the ability to perform essential job functions.

We also talked about addressing outside employment with new hires earlier in the hiring process. This will help us identify and prevent any potential conflicts of interest and ensure expectations are clear upon acceptance of employment.

Additionally, we confirmed that all newly hired employees must have reliable high-speed internet at home to ensure they can access required systems and perform their job duties effectively.

Position Summary

The Nursing Home Transition (NHT) Coordinator plays a vital role in helping individuals safely and successfully transition from nursing facilities back to community-based living. This position works closely with participants, families, service coordinators, healthcare providers, and external agencies to ensure services and supports are in place before, during, and after discharge. The NHT Coordinator is responsible for adhering to all program requirements, maintaining timely and accurate documentation, and providing consistent participant support throughout the transition process.

Education & Experience:

• Associate's or Bachelor's degree in Social Work, Human Services, Nursing, or a related field (Bachelor's degree strongly preferred).
• 1–2 years of experience in care coordination, case management, or related human services roles.
• Knowledge of Medicaid Waiver programs, Long-Term Services and Supports (LTSS), and Home and Community-Based Services (HCBS) strongly preferred.

What AUCP offers YOU:

Starting Hourly Rate: 21/hour, with the opportunity for performance-based increases.

• Flexible Schedule

• No on-call

• 15 Agency Paid Days Off (including 11 holidays)

• 18 PTO Days

• Paid Training Period

• Mileage Reimbursement

• Tuition Reimbursement

• Medical Insurance

• Company Paid Dental Insurance

• Company Paid Vision Insurance

• Company-paid life insurance with the option of adding additional for you and your family

• Up to 5% Match for 401(k)

Key Responsibilities

• Serve as the primary point of contact for nursing home residents interested in community reintegration through the NHT program.
• Collaborate closely with Community-Based Service Coordinators (HCBS SCs) and other care team members.
• Coordinate comprehensive transition planning with participants, families, facility staff, housing providers, and community agencies.
• Secure housing and necessary community-based services prior to discharge.
• Track each participant's progress, ensuring appropriate services and supports are in place pre- and post-transition.
• Maintain accurate, up-to-date documentation in compliance with federal, state, MCO, and internal policies.
• Support agency outreach and marketing efforts.
• Identify and address quality assurance issues using both direct observation and data analysis.
• Provide field instruction and mentorship for peers, as appropriate.
• Perform additional duties as assigned by the supervisor.
• Travel within the assigned region; occasional overnight travel required for training and seminars.

Skills & Knowledge:

• Experience working with individuals with disabilities or special needs.
• Strong skills in assessment, planning, and participant-centered service delivery.
• Excellent organizational, communication, and documentation skills.
• Ability to work effectively as part of an interdisciplinary team.
• Familiarity with community support systems, housing resources, health care, and human services.

Work Environment

• Frequent exposure to outdoor elements and varying weather conditions.
• Occasional driving in poor weather conditions may be required.
• Noise levels are typically minimal to moderate.

Employment is contingent on the successful completion of the following clearances

• PA State Police Background Check (e-PATCH)
• Child Abuse Clearance
• FBI Background Check
• MA Fraud Check
• Social Security Verification
• DMV Check