LTSS Transition Coordinator

DaMar Staffing Solutions•Indianapolis, IN

42d•$45,000 - $60,000•Remote

About The Position

The LTSS Transition Coordinator supports the LTSS Coordinator (or contracted provider) in executing the person-centered planning process during transitions of care for individuals moving between various levels of care.

Requirements

BA/BS degree with a minimum of two years of experience working with a social work agency, LTSS, healthcare, and/or the aged and disability industry; or any combination of education and experience which would provide an equivalent background.

Nice To Haves

Experience managing a community and/or facility-based care management caseload is highly preferred.
Experience working from home is a plus.

Responsibilities

Coordinate and manage transitions for individuals moving between different care settings, including home care, assisted living, and skilled nursing facilities.
Collaborate with healthcare providers, social workers, and other stakeholders to ensure a seamless transition process.
Ensure the effectiveness of the care plan and comply with contractual requirements for member outreach, including coordination and management of individual waivers (such as LTSS/IDD), behavioral health, or physical health needs.
Submit utilization/authorization requests to utilization management, ensuring documents support and align with the individual’s care plan.
Utilize tools and a pre-defined identification process to consult with the primary service coordinator, monitoring personalized care and support plan (PCSP) when a risk is identified concerning the member’s LTSS, etc.
Oversee the non-clinical requirements of members with chronic illnesses, co-morbidities, and/or disabilities, aiming for cost-effective and streamlined utilization of long-term services and supports.
Collaborate with the member’s chosen care team, which may consist of caregivers, family, natural supports, and physicians to document their short- and long-term service and support objectives, as directed by the member.
Identify members who may benefit from alternative service levels or other waiver programs.
May serve as a subject matter expert, mentor, or preceptor for new staff, contributing to formal training programs for associates and potentially engaging in process enhancement endeavors.
Promptly report critical incidents to pertinent internal and external entities, including state and county agencies such as Adult Protective Services and Law Enforcement.
Provide support and actively participate in appeal or fair hearings, member grievances, appeals, and state audits.