Transition Coordinator - QP (Multiple Counties)
Company: Vaya Health
Location: Danbury
Posted on: April 25, 2024
Job Description:
LOCATION: Remote - must live in or near Rowan, Stokes,
Rockingham, Caswell, Person, Granville, Vance, Franklin, Alamance
or Chatham County, NC. GENERAL STATEMENT OF JOB: The Transition
Coordinator QP (TC) is responsible for providing proactive
coordination of services to persons residing in or being diverted
from institutionalized settings prior to their transition to home
and community-based services. These services prepare
members/recipientss for discharge and assist during adjustment
period immediately following discharge from an institution. This is
a mobile position with work done in a variety of locations. The
Transition Coordinator QP will work with members/recipients in
their communities. Note: This position requires access to and use
of confidential healthcare information or protected health
information (PHI) as described in laws addressing patient
confidentiality, including, but not limited to, the federal HIPAA
law, the Confidentiality of Alcohol and Substance Abuse Patient
Records law, 42 CFR Part 2, and various state laws. As such, the
individual filling this position shall be required to be trained
regarding such laws and shall be required to observe those laws in
his/her capacity as an employee of Vaya Health. The individual
filling this position shall also sign a confidentiality statement
as an employee of Vaya Health.
ESSENTIAL JOB FUNCTIONS: Benchmarks: Transition Planning
- Must be able to manage an active caseload of
member/recipients/recipientss in transition planning.
- Will work with manager to create a yearly target number of
successful transitions based on state benchmark.
- Ensure that the Pre-Quality of Life survey is completed prior
to lease signing date.
- Educate providers of tenancy support about their respective
roles and responsibilities and of the TC's role and
restrictions.
- Adheres to boundaries within the In Reach, Transition,
Diversion policy and does not provide services or supports outside
of the scope of work. Monitoring
- Ensure that monthly updates are received for transitioned
members/recipients and submit auditing tool by deadline.
- Work alongside community providers (i.e., tenancy support,
medical health, etc.) to ensure they are providing needed services
Transition Planning: Transition Planning Process: The Transition
Coordinator QP will work alongside the Transition Coordinator LP to
ensure that any member/recipient who wishes to move to a more
inclusive setting, from the adult care home or state psychiatric
hospital, is provided with clinically indicated and appropriate
behavioral health services and supports and In Reach staff, care
management, and other Vaya departments necessary to ensure
transition/discharge planning begins at admission to the facility.
The Transition Coordinator QP will assist in developing the
transition team. To facilitate a successful transition, the
Transition Coordinator QP:
- Meet with the member/recipient, conduct clinical record review,
and ensure completion of necessary assessments as needed. An
assessment includes but is not limited to: diagnostic assessments,
comprehensive clinical assessments, and psychological
evaluations.
- Assists the member/recipient in developing an effective written
plan which will include linkage to necessary treatment and crisis
planning to enable the member/recipient to live independently in an
integrated community setting;
- Networks with the member/recipient and the member/recipient's's
family and supports to develop a thoughtful, organized, holistic
transition plan that addresses his/her community-based support
needs;
- Ensures discharge/transition planning is developed and
implemented through person-centered planning processes in which the
member/recipient has a primary role and is based on the principle
of self-determination while considering safety and well-being;
- Coordinate with the member/recipient, his/her family and
supports to identify and secure the Community resources necessary
to transition. Following basic hierarchical needs this includes but
is not limited to: housing, behavioral health services, medical
care, financial management, safety and security, and other
community supports that are needed for community living;
- Develop diagnostic impression prior to linkage of services to
ensure clinically appropriate services are in place during
transition.
- Use motivational interviewing techniques to ensures a thorough
North Carolina Person Centered Plan (NCPCP) is developed;
- Foster communication with institutions, provider agencies, and
other community and natural supports that will be involved in the
transition. Diversion: Transition Coordination function assumes
responsibility for being responsive to the transition needs
identified through the Department of Justice diversion process,
ensuring a member/recipient requiring diversion from an Adult Care
Home via the Referral Screening Verification Process (RSVP). The
Transition Coordinator QP then assists the member/recipient through
the transition planning process. This requires brokerage with high
end stakeholders such as hospitals, institutions, and other
community stakeholders. Each transition experience is unique and
may require multiple meetings of the team members or ongoing
communication to ensure the transition process occurs in an
organized, timely manner. In collaboration with the
member/recipient and the transition team, the Transition
Coordinator is responsible for establishing a transition team
planning meeting schedule that effectively meets the needs of the
particular transition. Use of therapeutic intervention may be
necessary to evolve and stabilize a member/recipient's transition
experience. The Transition Coordinator QP has responsibilities
throughout the transition, including on transition day. He/She must
be available to the transition team, including in person
participation and will ensure move-in logistics have been arranged
either directly or in partnership with other teams within the
LME/MCO (i.e. Housing specialists). Follow along is also part of
the transition process. Follow along should be sufficient to ensure
that a person's clinical and basic needs are identified and
addressed in a timely way that ensures the member/recipient does
not loose critical services or housing. Documentation The
Transition Coordinator QP is responsible for clear and concise
documentation of the transition process for each member/recipient.
This documentation will serve to inform the local organization,
state, and federal government. All contacts and interventions will
be documented in the member/recipient's administrative health
record. Collaboration: The Transition Coordinator QP will have
ongoing, respectful communication with all members/recipients
involved in the transition process. The Transition Coordinator QP
will work closely with the In Reach staff, care coordination,
hospital liaisons and other Vaya departments necessary to create,
implement and fulfill successful transition planning with
members/recipients. The Transition Coordinator QP will also be
involved in education with members/recipients, families, providers,
and stakeholders associated with Transitions to Community Living.
Other duties as assigned. QUALIFICATIONS & EDUCATION REQUIREMENTS:
Bachelor's degree in a Human Services field and two (2) years of
post-bachelor's degree accumulated experience with the population
served, or a bachelor's degree in a field other than human services
and four (4) years of full-time, post-bachelor's degree accumulated
experience with the population served. PHYSICAL REQUIREMENTS:
- Close visual acuity to perform activities such as preparation
and analysis of documents; viewing a computer terminal; and
extensive reading.
- Physical activity in this position includes crouching,
reaching, walking, talking, hearing and repetitive motion of hands,
wrists and fingers.
- Sedentary work with lifting requirements up to 10 pounds,
sitting for extended periods of time.
- Mental concentration is required in all aspects of work.
KNOWLEDGE, SKILL & ABILITIES: A high level of diplomacy and
discretion is required to effectively negotiate and resolve issues
with minimal assistance. This will require exceptional
interpersonal skills, highly effective communication ability, and
the propensity to make prompt independent decisions based upon
relevant facts. Problem solving, negotiation, and conflict
resolution skills are essential to balance the needs of both
internal and external customers. Must be highly skilled at shifting
between macro and micro level planning, maintaining both the big
picture and seeing that the details are covered. The Transition
Coordinator QP must have considerable knowledge of the MH/SU/IDD
service array provided through the network of Vaya providers.
Additional knowledge in Vaya Medicaid B and C waivers and
accreditation is helpful. The employee must be detail oriented,
able to organize multiple tasks and priorities, and to effectively
manage projects from start to finish. Work activities quickly
change according to mandated changes and changing priorities within
the department. The employee must be able to change the focus of
his/her activities to meet changing priorities. Proficiency in
Microsoft Office products (such as Word, Excel, Outlook,
PowerPoint, etc.) and Vaya information system is required.
RESIDENCY REQUIREMENT: This position is required to reside in North
Carolina or within 40 miles of the North Carolina border.
SALARY: Depending on qualifications & experience of candidate. This
position is non-exempt and is eligible for overtime compensation.
DEADLINE FOR APPLICATION: Open Until Filled APPLY: Vaya Health
accepts online applications in our Career Center, please visit.
Vaya Health is an equal opportunity employer.
Keywords: Vaya Health, High Point , Transition Coordinator - QP (Multiple Counties), Other , Danbury, North Carolina
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