Post Transition Coordinator - LP (Remote NC)

Vaya Health • Remote, Remote, NC, US, NC

13d • $62,994 - $81,892 • Remote

About The Position

The Post Transition Coordinator LP (Post TC LP) is responsible for providing proactive clinical intervention and coordination of services and resources to persons residing in & maintaining their home or wish to be rehoused as part of the Transitions to Community Living (TCL) program. The Post TC LP must understand the Olmstead Act and embrace the housing first model. The Post TC LP must enjoy problem-solving, can adapt to changing circumstances, adjust plans easily, be willing to change their approach or perspective when needed, and be able to work in a fast-paced environment to maintain a caseload. Post TC LP will take lead when the transition team is staffing member needs during weekly group supervision and during the Pre-Separation Huddle. Post Transition activities support individuals with maintaining their home in the community setting. They assist with promoting community inclusion, employment, and ensuring the appropriate level of services and supports are in place to ensure ongoing tenancy for the individual. These services support members/recipients with maintaining a home in the community of their choice. This is a remote position with work being completed in home/Vaya office. The Post Transition Coordinator LP will coordinate services/supports via Vaya technology, in collaboration with internal/external stakeholders. 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.

Requirements

• Master’s degree in a Human Services Field.
• Must be a Master’s Level Mental Health Clinician.
• 2 years of post-Bachelor’s degree accumulated experience with the population served if Bachelor’s degree was in Human Services.
• 4 years of post-Bachelor’s degree accumulated experience with the population served if Bachelor’s degree was in a field other than Human Services.
• Valid North Carolina clinical licensure (social work, counseling or psychology) is required.
• Proficiency in Microsoft Office products (such as Teams, Word, Excel, Outlook, PowerPoint, etc.) and Vaya information system is required.
• Must be highly skilled at shifting between macro and micro level planning, maintaining both the big picture and seeing that the details are covered.
• Must have considerable knowledge of the MH/SU/IDD service array provided through the network of Vaya providers.
• Detail oriented, able to organize multiple tasks and priorities, and to effectively manage projects from start to finish.
• Able to change the focus of his/her activities to meet changing priorities.

Nice To Haves

• Knowledge in Vaya’s Tailored Plan, State funded services, Medicaid B and C waivers and accreditation is helpful.

Responsibilities

• Supports members/recipients after they have moved into their unit, with the main objective to successfully retain participants in their community in partnership with the member/recipient’s behavioral health provider and care management.
• Utilizes the Post Transition Stratification to stratify members/recipients in high, medium, or low categories, directing goals and subsequent tasks to support the member/recipient.
• Supports members/recipients desire to be rehoused, reducing or preventing separations by rehousing the member/recipient when possible.
• Leads ongoing Treatment Team meetings with the member/recipient and the members/recipient care team until housing has been identified.
• Ensures that the Rehouse Plan is completed by the provider and member/recipient is supportive to help the member maintain the PSH placement once new housing options have been identified.
• Completes the appropriate subsidy documentation and requests the correct funding as financial needs arise to rehouse the member/recipient.
• Supports members/recipients with maintaining their ongoing PSH by reducing separation risk.
• Provides clear and concise documentation of the post transition phase for each member/recipient under TCL.
• Documents all contacts and interventions in the member/recipient’s Electronic Health Record (EHR) and the Transitions to Community Living Database (TCLD).
• Reviews the Community Inclusion Monthly Update (CIMU) forms and payee client statements to ensure the member/recipient is not at risk of losing housing or financial assistance.
• Uploads all documentation and notes into the member/recipient's record within 24 hours.
• Uploads and/or submits all receipts, items received form, and invoice payment request stamps to Vaya's Finance team within 48 hours.
• Supports maintaining the Master Spreadsheet (MSS) to maintain data entries for members/recipients assigned to their caseload to reflect current participant data points.
• Has ongoing, respectful communication with all members/recipients involved in the post transition and/or rehouse phase.
• Works closely with transition coordinators, housing - transitions, care coordination, provider network, TCL Community Liaison, hospital liaisons and other Vaya departments necessary to create, implement and successfully support members/recipients with maintaining TCL permanent supported housing.
• Educates members/recipients, LRP (Legally Responsible Person), families, providers, and stakeholders associated with Transitions to Community Living.
• Completes four (4) month reassessments by completing a CLA budget worksheet and CLA application to ensure the members/recipients meet ongoing CLA eligibility.
• Ensures the member/recipient has an active Social Security application or application on file.
• Works with the members/recipients provider to ensure they continue to appeal any SSA denials.
• Confirms ongoing CLA monthly payments to ensure Vaya's Finance team has the correct information to process payments monthly.
• Ensures the MSS accurately reflects the ongoing CLA amount.
• Supports the Special Assistance In-Home (SA-IH) designated staff with coordination of SA-IH annual recertification documentation (FL2 forms and SAIH Attestation forms) and provider linkage as needed.
• Supports the members/recipients with getting reconnected with SAIH funds by supporting with SA-IH application, obtain current FL2 form, and the Appendix E Supplement 2 form if SA-IH is discontinued.
• Ensures that all required SA-IH documents have been saved in the members/recipients EHR and MSS.
• Supports the Housing team by calling the members/recipients or provider to support with completing obtaining TCLV Biennials Recertification when they have been unable to receive a complete TCLV Biennials Recertification from the members/recipients.
• Other duties as assigned.

Benefits

• This position is exempt and is not eligible for overtime compensation.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level