The Acute Transitional Care Manager (ATCM) is responsible for proactive intervention and coordination of care to members and recipients of Vaya’s Health plan who are receiving care in an inpatient community hospital or Emergency Department in some instances who require complex care planning to alleviate inappropriate levels of care or care gaps through multidisciplinary team care planning, linkage and/or coordination of services across the MH/SU/IDD and other healthcare network(s) with existing or new care team members within the Acute Transitional CM professional scope. The ATCM is responsible for knowing and implementing organizational policies, Division and departmental specific guidelines. Activities may include but not limited to the following: In cooperation with community hospital discharge planning teams, participate in developing transition plans, educating staff and members regarding network services and supports with consideration of medical necessity, funding eligibility and appropriateness of recommendations relative to person centered, recovery principles and known best/appropriate practice. Develop, coordinate and link emergency discharge services (up to and including residential placement based on medical necessity, funding and service definitions or EPSDT for children/youth) for members who are inappropriately discharged from residential facilities (child or adult); coordination with Vaya’s FastTrack process; notifying Vaya Health Network of provider contractual concerns or through established process if quality of care or health and safety concerns; Notification and update of assigned community-based Care Manager (CM) and care team if member is currently assigned. Coordination and consultation with Vaya RN CM for transition management support. Transition to community-based CM post discharge. Participate in the development and implementation of best practice complex care strategies as identified by Vaya Health. Provide proactive and clear supervision supported by data to ensure supervisors and teams are meeting departmental and organizational benchmarks; and Collaborate with key stakeholders, network providers and non-network providers with particular attention to crisis, inpatient, 3-way bed contracts, NC START, etc. Engage and develop collaborative relationships with members using our Transitional Care Management and Tailored Care Management staff—such as our Care Managers and Peer Support Specialists—that use motivational interviewing techniques to understand the root causes that lead to exacerbation of symptoms and the use of emergency services or inpatient admissions Address Unmet Health-Related Resource Needs that may be barriers to care or impacting the health of members Utilize ADT feeds and alerts to ensure prompt, efficient coordination and support This position works with staff, community partners and members in Vaya Health catchment.