Transition Coordinator LP
Company: Vaya Health
Location: Pittsboro
Posted on: January 26, 2023
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Job Description:
LOCATION: Rowan County, NC, Chatham County, NC, Alamance County
County, NC, and Stokes County, NC. Incumbent must live in the state
of North Carolina
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 as part of the Transitions to Community
Living (TCL). 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 LPwill
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:Transition Planning* Must 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 TCL 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* Will be
available for staffing and clinical consultation to other TCL 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 TCL 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.
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.
QUALIFICATIONS & CREDENTIALING REQUIREMENTS:
PHYSICAL REQUIREMENTS: Person in this position is required to have
close visual acuity to perform activities that include 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.
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:Valid licensure or certification in profession (social
work, counseling or psychology) is required. Acceptable licenses
are Licensed Clinical Social Worker (LCSW), Licensed Clinical
Social Worker Associate (LCSWA), Licensed Clinical Mental Health
Counselor (LCMHC), Licensed Clinical Mental Health Counselor
Associate (LCMHCA), Licensed Clinical Mental Health Counselor
Supervisor (LCMHCS), Licensed Psychological Associate (LPA),
Licensed Marriage and Family Therapist (LMFT) or Licensed Marriage
Family Therapist Associate (LMFTA).
LOCATION REQUIREMENT: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.This position is required to reside in North Carolina
or within 40 miles of the North Carolina Boarder.
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 http://www.vayahealth.com/careers-overview/
Ind.001
Vaya Health is an equal opportunity employer.
Keywords: Vaya Health, Durham , Transition Coordinator LP, Other , Pittsboro, North Carolina
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