Transition Coordinator - LP (Multi-Counties)
Company: Vaya Health
Location: Hendersonville
Posted on: November 15, 2024
Job Description:
LOCATION: Remote - must live in or near Granville, Buncombe,
Haywood, McDowell, Henderson, Burke, Orange, Vance, Wake, Alamance,
Guilford, Person, Caswell, Durham, or Franklin County, North
Carolina. This position will serve these counties. Incumbent must
reside in North Carolina or within 40 miles of the NC border.
GENERAL STATEMENT OF JOBThe 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. ESSENTIAL JOB FUNCTIONSTransition PlanningMust be
able to manage an active caseload of members/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 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. 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 servicesWill be available for staffing
and clinical consultation to other team members as needed
Transition Planning: Leading the Transition Process:The Transition
Coordinator LP 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 LP will assist in developing the
transition team.
To facilitate a successful transition, the Transition Coordinator
LP:
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 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 tothe
transition needs identified through the Department of Justice
diversion process, ensuringa member/recipient requiring diversion
from an Adult Care Home via the Referral Screening Verification
Process (RSVP). The Transition Coordinator LP 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 LP 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 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. Collaboration: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. KNOWLEDGE, SKILL & ABILITIESA 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.
QUALIFICATIONS & EDUCATION REQUIREMENTSMaster's degree in a Human
Services field with clinical licensure (LCSW, LCMHC, LPA, or LMFT)
and two (2) years of post-human services bachelor's degree with
accumulated experience with the population served or four (4) years
of full-time, post non-human services bachelor's degree with
accumulated experience with the population served.
Licensure/Certification RequirementsMaster'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)
PHYSICAL REQUIREMENTSClose 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.
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 exempt and is not 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, Knoxville , Transition Coordinator - LP (Multi-Counties), Other , Hendersonville, Tennessee
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