Overview
ESSENTIAL DUTIES AND RESPONSIBILITIES
• Become familiar with all aspects of the FREED program in order to assist consumers in
understanding their level of independence on a continuum as well as their service needs.
• Provide information, support and training to assist consumers in achieving stated
independent living goals and/or make referrals to appropriate resources and agencies.
• Obtain, evaluate, and document comprehensive information related to community based
long-term care services and supports (LTSS) and develop a framework of possible options
available that allow individuals and stakeholders to make informed choices.
• Provide enhanced information and assistance by working with the consumer to identify the
individual’s long and short term needs, identifying resources to meet those needs, providing
referrals to identified resources, and, where appropriate, providing warm hand-offs, and
following up to ensure that a consumer’s needs have been met.
• Provide individual advocacy, independent living skills training, and housing assistance
services to consumers.
• Providing benefits counseling, advocacy, and guidance to consumers in benefit areas
including Social Security, MediCal and other medical benefits, IHSS, housing programs such
as Section 8, employee and other benefits programs for people with disabilities.
• Provide peer support services and information on various peer support groups and activities
to consumers.
• Provide information to consumers, community service providers, educators and interested
community members about assistive technology equipment, programs and services.
• Refer potential personal assistants to consumers. When necessary, make home visits to
consumers.
• Manage personal assistance registry including conducting orientation and interviews of
personal assistants for placement on the registry, and providing consumers with information
and training on managing personal assistants and/or referrals to appropriate resources.
• Become involved annually with at least one community awareness/education and systems
advocacy project.
• Develop and conduct presentations on FREED and community based LTSS options and
resources. Participate in outreach events, educational workshops, and resource
development trainings on various community based long term care solutions.
• Perform transition services including related services in compliance with the Department of
Rehabilitation Transition grant and California Community Transition (CCT) project, according
to the guidelines, rules, and regulations, established by CMS, the CA Dept. of HHS, and
DHCS.
• Coordinate MDS 3.0, Section Q referral process from nursing facilities for residents
interested in community living, contact referred residents to provide information and
counseling on available home- and community-based services, and assist with transition
services.
• Establish an Independent Living Plan (ILP) for transitioning purposes.
• Working directly with nursing facility residents, their families, physicians, service providers
and significant others to develop a comprehensive service plan. Including coordinating
services and service providers.
• Complete CCT Treatment Authorization Requests (TARs) through Medi-Cal.
• Establishing and maintaining working relationships with nursing facility and hospital staff,
Long-Term Care Ombudsmen staff and volunteers, multiple community health and social
services agency staff, county Medi-Cal eligibility staff, state and federal agency staff (e.g.,
Social Security Administration), regional centers and providers of medical and social
supports, and others.
• Utilize IL service team and partner resources to create linkages between inpatient facility
residents and services, supports, agencies, housing, income, and additional resources
necessary to move from the inpatient facility to a safe and supportive community
environment.
• Coordinating the date of discharge from the inpatient facility with the various programs and
services, including Medi-Cal eligibility, in the community setting.
For full Job Description: https://freed.org/wp-content/uploads/2026/07/FREED-TransitionCoordinator-Job-Description-2018.pdf
Please send resumes to: jobs@FREED.org
Wage range: $20 to $22.00
Minimum Education and Experience