Options Counselor- Hospital Liaison

Location: South Bend
Department: AAA
FLSA Status: Non-Exempt
Job Type: Full Time


This full-time position is responsible for providing information and options to individuals who are in the hospital and referred to REAL Services from Beacon Health Systems. The Options Counselor- Hospital Liaison will be housed at Beacon Memorial Hospital and is responsible for enhancing the partnership and collaboration between Beacon Health System staff and the Agency. This position provides options counseling, service plan development, assists with application for Medicaid, and establishes initial service plans as appropriate. This position provides decision support to inquirers while assisting them in making educated decisions about options that are available in their community to maintain independence. The objective of this position is enhanced coordination with the individual’s medical team and quickly establish in-home services.

ESSENTIAL DUTIES include the following. Other duties may be assigned.

  • Participate in care coordination meetings with hospital staff, individuals and other members of the individual’s health care team.
  • Meet with individuals, families, and caregivers to provide comprehensive assessments and options counseling.
  • Screen clients for potential eligibility for funding sources and programs.
  • Assist in accessing home and community based services that would meet identified
  • Assist individual with completing Medicaid application, gathering and submitting required documents, attending application interview, and follow-up until eligibility is determined by the Division of Family Resources.
  • Contact individual’s preferred vendors to secure provider.
  • Develop initial service plan and submit Eligibility Determination recommendations.
  • Complete Expedited Waiver Eligibility Assessments, Options Counseling, and target for in-home services as defined by the Division of Aging.
  • Transition individual to long-term care management provider when applicable.
  • Complete required documentation and reports in a concise and timely manner.
  • Coordinate work flow and coverage with other agency staff members.
  • Attend staff meetings and training sessions as scheduled.
  • Work with direct supervisor and/or other disciplines when additional consultation is required.
  • Serve clients in a manner that is empowering, patient, compassionate, and person-centered.
  • Practice Needs Based Service Model.
  • Provide an interactive experience and guidance in consult with the individual, their representative, and informal supports, as applicable.
  • Identify the individual strengths, values, and preferences including identification of all current formal and informal supports.



The person holding this position must be comfortable being in a hospital setting, as well as going to clients’ homes as needed. Excellent communication skills and a collaborative mind-set are vital to the success of this position. Options Counselors must be well versed in the various funding sources, as well as resources and programs available in the community that are beneficial to the inquirer. It is essential that work is completed in a quality and timely manner and in accordance with program standards and guidelines. It is sometimes necessary to use some analysis and judgment in determining the best procedure to follow or how to best communicate information to caregivers and inquirers who may be in stressful situations. Efficient and accurate work is critical to ensure initiation of services.


Bachelor’s degree (BA or BS) from an accredited four-year college or university in social work, psychology, counseling, gerontology; or a license as a registered nurse with one year of experience in human services; or Bachelor’s degree  in any field with a minimum of two years, full-time direct services experience with elderly or disabled persons.  This experience must include assessment, plan of care development, implementation, and monitoring; or applicant may have a Master’s degree in a related field to substitute for the required experience. Previous work in a hospital setting is beneficial, but not required.

Obtain and maintain Indiana FSSA Division of Aging Care Management certification.


  • Knowledge of in-home and community-based services, funding sources, and eligibility.
  • Knowledge of options, funding sources, services, resources, and information available through REAL Services and in the
  • Excellent communication skills, both orally and in writing with good interviewing skills.
  • Ability to assess specific needs both in person and on telephone; ability to develop rapport quickly and to empathize and understand individual behaviors.
  • Ability to organize information, prioritize assignments, complete tasks in a timely manner, and to use sound judgment.
  • Ability and attitude to work productively independently and cooperatively and relate to the needs of the staff, the individual, and the agency.
  • Ability to follow instructions and procedures, to interpret information, and to complete assigned tasks in accurate, concise, and detailed manner.
  • Ability to operate office equipment, including but not limited to phone, facsimile, copy machines, and computer equipment.
  • Ability to use Microsoft Word, Excel, Teams and other computer programs.


The work demands sound judgment be exercised in selecting the most tactful approach in communicating with individuals.  All documentation must be accurate and timely.  The work is repetitive in nature inasmuch as the same tools, forms, and procedures are utilized routinely, but does involve variables and considerations when dealing with diverse situations.  Contact is primarily face-to-face in a hospital setting, as well as in individuals’ homes on a less frequent basis. Independent travel is expected. Travel will primarily be within St. Joseph County, but may be needed throughout the A2AA service area for client interactions and throughout the state for trainings on a less frequent basis. May have to conduct appointments after normal business hours.



  • This position will work closely with Beacon Health System staff, specifically Nurse  Navigators.
  • Direct interactions with clients, their families, and caregivers. Primary contact will be with individuals who experienced a setting change.
  • Direct interactions also occurs with community professionals and agencies, including in-home services providers.
  • Will interact Agency staff, including other members of the Care Management Department, as well as other departments.



The physical demands and work environment described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.  While performing the duties of this job, the employee is usually seated, standing, or walking at will in a typical office setting. Very limited physical effort required.

  • Valid driver’s license and a dependable vehicle required.
  • (For new employees starting 9/1/20 or after) Password protected home personal internet assess of a quality good enough so that you may may preform the duties required, including

but not limited to basic web browsing and data entry, make internet based phone and video  calls, watch webinar, and participate in online meetings.

  • Must maintain the Agency’s required car insurance coverage ($100,000/$300,000/$100,000) at time employment begins and maintain it throughout the duration of employment.
  • Regular and reoccurring travel to meetings, training, client visits and the Elkhart General campus of Beacon Memorial Health Systems.



  • Must learn Vision Link.
  • Must learn the State approved case management system.
  • Successful candidate must submit to a pre-employment drug screening, drivers check, National Sex Offendors check, and a limited criminal history
  • Proof of educational credentials is required at time of employment.
  • This position has a 6 month probationary period.
  • Must sign non-compete clause.
  • Must complete and maintain Indiana FSSA Division of Aging Care Management Certification.

Apply for this position

Thank you for applying for this position. Please remember to fill out and upload your Pre-Employment Application and resume.

Download the Pre-Employment Application at: https://realservices.org/app

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