- Support members transitioning from inpatient settings to the appropriate lower or lateral level of care
- Provide subject matter expertise, within scope, regarding member's physical and/or behavioral health to support the development and delivery of a whole person approach to Care Management
- Work collaboratively with other Alliance staff, behavioral health providers, primary care physicians, specialty care providers and other community partners and stakeholders to support members in their home communities
- Conducts on site visit the member during their stay in an
- institution (e.g., acute, subacute and long–term stay facilities)
- Conduct outreach to the member's providers.
- Obtain a copy of the discharge plan and review the discharge plan with the member and facility staff.
- Facilitate clinical handoffs.
- Refer and assist members in accessing needed social services and supports identified as part of the transitional care management process, including access to housing.
- Assist the member in obtaining needed medications prior to discharge, ensure an appropriate care team member conducts medication reconciliation/management and support medication adherence.
- Develop a ninety (90) day post-discharge transition plan prior to discharge from residential or inpatient settings, in consultation with the member, facility staff and the member's care team, that outlines how the member will maintain or access needed services and supports, transition to the new care setting, and integrate into their
- community.
- Communicate and provide education to the member and the member's caregivers and providers to promote understanding of the ninety (90) day post-discharge transition plan.
- (Assist with scheduling of transportation, in-home services, and follow-up outpatient visits with appropriate providers within a maximum of seven (7) Calendar Days post-discharge, unless required within a shorter timeframe.
- Ensures follows up with the member within forty-eight (48) hours of
- discharge.
- Conduct In reach and transitions for Special Populations receiving care in Inpatient settings (State Hospitals, PRTF's)
- Appropriately escalate high risk/high visibility and/or complex barriers/needs members who may have difficulty transitioning out of the facility in a timely manner to supervisors. High risk can involve Health and Safety of a member, staff, or organizational risk
- Review cases with clinical complexity with direct supervisor and follow escalation protocols to ensure timely engagement from members or our Medical Team and Provider Networks
- Obtain information releases that will improve care management activities on behalf of the member
- Reports care quality concerns to Quality Management as needed
- Ensure all clinical documentation (e.g. goals, plans, progress notes, etc.) meet state, agency, and Medicaid requirements
- Ensure accuracy and quality of Warm Hand Off summaries
- Follow administrative procedures and effectively manages caseload
- Review, validate and interpret risk stratification data and population health groups and recommend changes or adjustments to care management approach as needed
- Utilize data to analyze needs of the members we serve, guide staff training development, identify resource needs and consistency of workflow implementation across disciplines
- A demonstrated Knowledge of the assessment and treatment of mental health, substance abuse, intellectual and developmental disabilities,
- Knowledge of legal, waiver, accreditation standards and program practices/requirements.
- Knowledge of the Alliance Health service benefit plans and network providers.
- Person Centered Thinking/planning
- The employee must be detail oriented,
- Ability to independently organize multiple tasks, priorities, and to effectively manage an assigned caseload under pressure of deadlines.
- Exceptional interpersonal skills, highly effective communication ability,
- Ability to make prompt independent decisions based upon relevant facts and established processes.
- Problem solving, negotiation and conflict resolution skills
- Proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) is required.
- Medical, Dental, Vision, Life, Long Term Disability
- Generous retirement savings plan
- Flexible work schedules including hybrid/remote options
- Paid time off including vacation, sick leave, holiday, management leave
- Dress flexibility
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Description
The Transition Coordinator II provides Transitional Care Management and Physical Health Consultation for members with physical and/or behavioral health needs in Acute Care facilities, State Operated Developmental Centers, and Justice System settings. For Transition Coordinator II's assigned to a facility, there will be active and onsite participation in discharge planning beginning with admission.
This position will allow the successful candidate the ability to work remote certain days of the week. The employee will also be required to come into the office closest to their home office location on certain days as approved by their supervisor. This position will require travel within the communities Alliance serves.
Responsbilities & Duties
Provide Care Team Support
Education & Experience
Graduation from an accredited school of Nursing and three (3) years of full-time, post degree experience providing care management, case management, care coordination, discharge planning, or utilization management to members with Behavioral Health and Physical Health conditions in a behavioral health, medical, or managed care setting. Must have a valid, active RN license in North Carolina.
Or
Master's degree from an accredited college or university in Human Services or related field and at least two (2) years of full-time, post graduate degree experience providing care management, case management, care coordination, discharge planning, or utilization management to members with Behavioral Health and Physical Health conditions in a behavioral health, medical, or managed care setting. Must have a valid, active Occupational Therapist clinical license in North Carolina.
Preferred: NACCM, NADD-Specialist, Health Education Specialist, and/or CBIS certification preferred.
Knowledge, Skills, & Abilities
$66,240.00 to $86,112.00/Anually
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.
An excellent fringe benefit package accompanies the salary, which includes:
