Manager, Care Transition Office

The Care Transition Office (CTO) ensures seniors receive continuous care as they come into and move between different NTUC Health services within Integrated Community Care Provider (ICCP) framework.

Its role includes:

• Connecting Services: Serving as the main link between hospitals, social services, and NTUC Health's and ICCP's various care options-like home care, nursing homes, and active ageing centres-to make sure clients have a smooth experience.
• Improving Care Journeys: Creating clear and efficient referral processes so seniors can easily move from hospital care to community support, and within community care services as their needs evolve, without delays.
• Boosting Teamwork: Leading efforts to identify gaps in care, simplify how we work together, and make our services easier for seniors and their families to access.

Manager, Care Transition Office plays a critical dual role: establishing NTUC Health's centralized assessment capability and driving internal care transition integration. As the lead for this function, this role will scope assessment workload demand (InterRAI CU), optimize care coordination handoffs between services, and support NTUC Health in achieving the aim of a single care plan for clients .

Key Responsibilities

• Assessment Capability Scoping & Management: Establish operational guidelines for centralized assessment support (InterRAI CU) across Senior Care Centres, Home Care, and Community Social Services directly conduct assessments while evaluating workload volume to determine future team scaling (up to 4 assessors). Be willing and able to eventually become a master trainer for InterRAI for an envisaged train-the-trainer model.
• Internal Care Coordination Optimization: Streamline internal onboarding and transfer processes, working closely with Care Coordinators across NTUC Health to standardize handoffs and eliminate transition bottlenecks.
• One Care Plan Strategy Integration: Contribute towards the design, pilot, and evaluation of journey-based integration models that unify multidisciplinary care plans into a single client record.
• Quality & Regulatory Compliance: Ensure all assessment workflows adhere to AIC guidelines, MOH regulatory standards, and internal clinical/social governance frameworks.
• Team Supervision (Phase 2): Recruit, onboard, train and supervise junior Care Assessors as assessment demand expands.

You should have:

• A Degree in Nursing, Social Work, Occupational Therapy, Physiotherapy, or Healthcare Management.
• Minimum 5 years of clinical, social work, or care assessment experience in eldercare or community health settings, with demonstrated project or team leadership.
• Certified InterRAI Assessor (or eligible/willing to undergo immediate certification).
• Strong process optimization and change management skills, with experience navigating cross-division workflows.
• Strong interpersonal and engagement skills.
• Analytical mindset with the ability to interpret assessment workload data to inform manpower planning.

It would be great if you:

• Possess prior involvement in health system integration, pilot project implementations, or EMR/care management system redesigns.
• Hold advanced qualifications in Gerontology or Healthcare Operational Excellence (e.g., Lean/Six Sigma).