MFP-OC/ Nursing Facility Transitions Coordinator, Center for Living & Working, Inc. (Worcester, MA)

  • Reports To: IL Manager
  • Supervision exercised: None
  • Exempt or Non-Exempt Status: Non Exempt

Center for Living & Working, Inc. (CLW) is located in Worcester, Massachusetts and is a 501 (c)(3) non-profit agency founded in 1975 by a core group of young adults with disabilities. CLW is a consumer directed, multi-programmed, multifaceted agency, dedicated to the empowerment of all persons with disabilities to live as independently as possible.  CLW provides four core services: Advocacy, Skills training, Peer support and Information and Referral. 


  • Provide consumer-directed and interactive decision-support to consumers, family members, caregivers and/or significant others in hospitals, nursing facilities, rehabilitation facilities, and community settings who are planning for long term services and supports, including those who need assistance transitioning from nursing facilities to the community.
  • Outreach to hospitals, community agencies, nursing facilities, and other long-term care facilities to inform the individuals and staff regarding options counseling and available transition supports.   Gather information necessary to ensure services and support options provided and referrals made are viable and appropriate based on the consumer’s preferences, needs and goals, as determined by the consumer.
  • Ensure timely and appropriate referrals and follow-up is made.
  • For individuals requesting nursing facility transition supports, develop a person-centered transition plan to inform and guide individuals of options for community living; assist with application for HCBS waivers, if applicable. Coordinate the transition from the facility-based to community-based setting through the provision of transitional assistance services such as housing search, coordination/purchasing of Transitional Assistance goods and services, and post transitional coordination and support.
  • Responsible for timely completion of data entry into multiple data systems to record, collect, and maintain current updated clinical and demographic information on consumers; assist IL Department with completion of required monthly and quarterly reports.
  • Maintain and contribute to a resource database on community organizations, long term care services and support options, public and private payer resources, applications, etc.
  • Maintain consumer service records and follow-up on referrals.
  • Participate in internal and external trainings to expand knowledge base and improve quality of services provided.

Other duties as assigned.

Essential Functions:

  • This position requires frequent communication (orally and/or in writing) with consumers, staff, medical providers, state agencies, business partners/vendors and other third parties;
  • This position requires the ability to conduct group presentations;
  • This position requires the ability to understand the requirements of Options Counseling and the MFP and Nursing Home Initiative programs and to be able to assess, teach, evaluate, educate, direct, refer the consumer/guardian regarding the scope and responsibilities of the programs;
  • This position requires the ability to travel within service area and beyond as needed;
  • This position requires the ability to accurately enter information into database;
  • This position requires the ability to use office machinery, including calculators;
  • This position requires the ability to remain in a stationary/standing position for extended periods of time;
  • This position requires the ability to maintain strict confidentiality for the relevant population (consumers);
  • This position requires the ability to write an individualized care plan.

Preferred Qualifications:


  • High School or equivalent (GED) required; Bachelor Degree in related field (health, social service or human services preferred) required. With state authorization, Bachelor Degree requirements can be waived for relevant years of related experience.


  • Minimum of 2 years related experience required working with community resources and local service system for persons with disabilities/(older persons) and how to arrange for services;
  • Discharge/transition planning
  • Excel, Microsoft Office, data base management
  • Information & Referral

Teaching Independent Living skills and providing advocacy while promoting self empowerment

Possess the ability to:

  • Work independently and as a team member
  • Work effectively with individuals with diverse disabilities and cultures
  • Prioritize and meet deadlines
  • Problem solve
  • Provide guidance and advocacy

Familiarity with:

  • Independent Living issues and philosophy;
  • MassHealth, state agencies and provider service system available to serve individuals with disabilities/(older persons);
  • State and Federal housing regulations;
  • Civil rights for individuals with disabilities.

This job description is subject to change at any time.

Individuals with disabilities strongly encouraged to apply.

Contact: Deb Ethier at