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Transition Coordinator LP

Company: Vaya Health
Location: Jefferson
Posted on: November 25, 2022

Job Description:

GENERAL STATEMENT OF JOB:The Transition Coordinator LP (TC) is responsible for providing proactive intervention and coordination 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/recipients 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 LP 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.

  • Must be able to manage an active caseload of members/recipients 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 roles 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.
    • Meet with the member/recipient, conduct clinical record review, and ensure completion of necessary assessments as needed. An assessment include 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 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.
      • 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
      • Will be available for staffing and clinical consultation to other team members as needed
        • The Transition Coordinator LP 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.
          • The Transition Coordinator LP will have ongoing, respectful communication with all members/recipients involved in the transition process. The Transition Coordinator LP 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
            A Master's Degree in a Human Services is required with two years of post-bachelor's degree with accumulated experience with the population served.
            graduate of a college or university with a bachelor's degree in a field other than human services and four years of full-time, post-bachelor's degree with accumulated experience with the population served.
            • Be a master's-level fully Licensed or provisionally Licensed Clinical Social Worker (LCSW), fully Licensed or provisionally Licensed Clinical Mental Health Counselor (LCMHC), fully Licensed or provisionally Licensed Psychological Associate (LPA), fully Licensed or provisionally Licensed Marriage and Family Therapist (LMFT) or licensure as a Registered Nurse (RN)
              • 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 OF JOB: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, arbitration 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 LP must exhibit an extensive understanding of the Diagnostic and Statistical Manual of Mental Disorders (current version), and 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.
                Licensure: Be a master's-level fully Licensed or provisionally Licensed Clinical Social Worker (LCSW), fully Licensed or provisionally Licensed Clinical Mental Health Counselor (LCMHC), fully Licensed or provisionally Licensed Psychological Associate (LPA), fully Licensed or provisionally Licensed Marriage and Family Therapist (LMFT) or licensure as a Registered Nurse (RN)
                SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.
                Residency Requirements: In accordance with the BH and I/DD Tailored Plan requirements mandated by the NC Department of Health and Human Services, certain Vaya Health positions are required to be filled by individuals who reside in North Carolina, meaning someone who establishes a legal domicile in North Carolina and pays income tax in North Carolina, or resides within 40 miles of the North Carolina border. New hires from outside of North Carolina will have 60 days from the date of hire to meet this requirement, if applicable to the position.
                DEADLINE FOR APPLICATION: Open until filled
                APPLY: Vaya Health accepts online applications in our Career Center, please visit Ind.001
                Vaya Health is an equal opportunity employer.

Keywords: Vaya Health, Winston-Salem , Transition Coordinator LP, Other , Jefferson, North Carolina

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