Integrated Care Coordinator - Community Transitions Liaison

Company: Mystic Valley Elder Services
Location: Malden
Posted on: February 28, 2026

Job Description:

Job Description Job Description Integrated Care Coordinator - Community Transitions Liaison Act as the onsite point of contact for residents, families, and skilled nursing facility (SNF) staff as relates to transitions from SNF to the community with focus on coordination with discharge planning to mitigate issues that may impact nursing facility residents' ability to successfully transfer to the community. Schedule: This is a Local Union 509, full-time, non-exempt (35 hour/week) position. We offer a hybrid work schedule (once training is complete.) No nights or weekends. Compensation: Starting annual salary range is $53,105.78 - $57,210.90. Being bilingual is not a requirement for this role, but we recognize it as an asset and offer an additional 6% bilingual designation for Spanish, Haitian Creole, Russian, Vietnamese, Cantonese or Mandarin. Enjoy benefits that start as of day 1 of employment and our generous paid time off package. With a refreshing culture that is supportive, collaborative, and encouraging of diverse perspectives and backgrounds and a satisfying balance between your work and personal life, why not join the Mystic Valley Elder Services' Team! Depending on your role and your hours, we offer: Flexible scheduling Competitive salaries Medical, Dental, and Vision starting day 1 403b Retirement Plan with agency contribution after 2 years of employment 3 weeks accrued Vacation time 3 weeks accrued Sick time 13 Paid Holidays 30 personal hours Ample free parking Tuition reimbursement Employee referral bonuses of up to $2,000 Job Activities Job activities of the position are below. Additional duties may be assigned as required. Top Key Activities: Have an onsite presence at each assigned nursing facility on a weekly basis to increase awareness of community support and services and introduce transition to community as a potential option. Identify and engage with all new nursing facility residents to develop a plan for transitioning to the community. Conduct assessments to determine the appropriateness for discharge to the community and complete referrals to other state programs to ensure timely transition. Coordinate with ASAP nursing, staff at the SNF, state programs and care teams. Maintain accurate consumer information in Aging and Disability system in accordance with Executive Office of Aging and Independence, Mystic Valley Elder Services, and MassHealth standards. Other Activities: Attend required training(s) Cross collaboration with all departments for best practices Document per contract and MVES/AGE requirements. Key Success Measures: Quality metrics as determined by MVES in accordance with contract. Qualifications: A Bachelors' degree from an accredited school in social work, psychology, counseling, human development, nursing, sociology, criminal justice, public health, public policy, or gerontology, and at least two years of experience in counseling, casework or case management preferably with older adults and/or the disabled population Previous experience in a human service/community-based setting preferred Excellent interpersonal skills with demonstrated ability to communicate across all levels, including staff, family and external partners Ability to maintain confidentiality while working with sensitive information or in sensitive situations Highly resourceful team player, with the ability to work effectively independently or as a team Demonstrates a willingness to take on new tasks with a general attitude that no task is too small, impossible, or cannot be improved Expertise in the following platforms: Microsoft Office (Word, Outlook, Teams, Excel, and PowerPoint), Adobe Pro, Zoom and other web-based applications Physical Requirements of the Job: Ability to lift, push, pull and carry objects frequently weighing up to 10 to 15 pounds. Ability to climb up and down stairs unassisted. Ability to travel to the community to perform visits Private transportation and driver's license Work requires regular standing, stooping, and bending. Mystic Valley Elder Services is an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. Job Posted by ApplicantPro

Keywords: Mystic Valley Elder Services, New Bedford , Integrated Care Coordinator - Community Transitions Liaison, Healthcare , Malden, Massachusetts