Transition Specialist

 Job Title: Transition Specialist

Reports To: Transition Coordinator

Program:  Open Doors Transition Center Project

FLSA Status: Non-Exempt

Job summary: 

The Transition Specialist leads all efforts for individuals residing in institutions to facilitate and coordinate the transition process back into the community through the development of a comprehensive plan, advocacy and one-on-one direct support.   

Essential Functions:

  • Receive referrals from the Open Doors Transition Coordinator and ensure the transition process is followed through for each individual
  • Provide counseling and information for individuals and families who are considering, or are in the process of transitioning
  • Coordinate visits to institutions, provide potential participants with objective information regarding available home and community based services, participate in discharge planning and coordinate with other relevant social services agencies involved in the discharge and transition care of the individual
  • Explain peer outreach program to potential participants and if appropriate provide referral to peer outreach program
  • Develop and facilitate person-centered plans effective for the 90-day transition period, secure qualified housing, coordinate home and community based services during the transition period and subsequently ensure continuation of services after the 90-day transition period
  • Collaborate with supervisor to determine barriers to transition
  • Collaborate with supervisor in addressing transition barriers related to medical condition or counseling need
  • Ensure all significant client data and service provision details are current and accurate and that they are documented in a timely manner into ARISE’s and NYAIL’s databases
  • Attend trainings, meetings and other agency-related activities
  • Uphold the codes of conduct and ethics as well as all ARISE policies and procedures
  • Exercise sound judgment as a matter of course, and hold protected health information and other sensitive information in the strictest of confidence in accordance with ARISE and HIPAA policies
  • Perform other program-related duties as assigned


  • Bachelor’s Degree in Human Services or a related field or equivalent experience
  • Working knowledge of issues faced by individuals of all ages who are in need of long-term care, particularly with those related to nursing home transition
  • Knowledge of NHTD, TBI and/or OPWDD waivers as well as other supports, services and programs available to participants
  • Proficiency in Microsoft Word and Excel
  • Clean driver license and reliable transportation for travel in multi-county region