TCL Transition Coordinator (Full Time, Hybrid, North Carolina Based)

Alliance Health•Durham, NC

2d•$26 - $33•Hybrid

About The Position

The TCL Transition Coordinator is responsible for assisting individuals who have agreed to community living exiting an institutional care setting. This position will support a person in securing and managing appropriate services, housing and community resources and requires a high level of collaboration and problem solving with internal and external stakeholders. This is a full-time hybrid opportunity. There is no expectation of coming into the office routinely, however, the selected candidate must be available to report onsite to the Alliance Office (Morrisville, North Carolina) for business meetings as needed. The successful candidate will also be required to travel throughout Wake County and surrounding counties (including ones outside of Alliance’s catchment area) to meet with members, providers and/or other community stakeholders.

Requirements

Bachelor’s degree in a human services field or licensure as a RN plus three (3) years of relevant experience working directly with individuals with SED or SMI.

Nice To Haves

Master’s degree from an accredited college or university in Human Services field and one (1) year of full-time, post degree work experience with social service agencies is preferred.
Knowledge of resources and systems in the community that can assist with eliminating SDOH barriers to treatment and whole person living.
A high level of diplomacy and discretion is required
Problem solving, negotiation, arbitration and conflict resolution skills
Must be highly skilled at shifting between macro and micro level planning
Detail oriented
Ability to organize multiple tasks and priorities, and to effectively manage projects from start to finish.
Work activities and quickly adapt to mandated changes and priorities within the department.
The ability to change the focus of his/her activities to meet changing priorities.
Proficiency in Microsoft Office products (such as Word, Excel, Outlook, PowerPoint, etc.) is required.

Responsibilities

Assist the treatment team with members transitioning to the community from institutional care settings to community-based care
Utilize person-centered planning, motivational interviewing and assessments to review information and develop rapport with the members supported
Obtain necessary releases of information that will improve care management activities on behalf of the member
Provide education to the individual/legal guardian on the behavioral health, physical health, and other recommended services based on Comprehensive Clinical Assessment (CCA) including how these services will be part of the of resources to support the individual in residing in supportive housing.
Ensure that assessments and plans are updated, as needed, whenever the members’ life circumstances change
Complete Administrative assessments/ plans of care for the needs identified in the assessments and complete the interventions identified as needed
Ensure compliance with all DOJ Settlement requirements and adhere to best practice standards for assessments and treatment planning
Review BH crisis plans and care plans to ensure the presence of integrated care interventions and these plans reflect the needs and desires of members
Ensure that all team members and stakeholders involved with members are aware of how to train, manage and mitigate crisis events, behavioral and physical, that the member may experience
Ensure referrals to RN/OT Evaluator Team when there are physical health and/or significant functional health concerns noted in the CCA
Assist persons with identifying initial and rehousing housing options based on preferences and needs and discuss barriers to housing
Ensure financial supports needed for the individual is addressed with the Transition Team and in the PCP
Convene and facilitate transition meetings to ensure that a person’s housing, clinical activity needs, and issues related to health and safety are identified and addressed on a timeline
In-person visits as defined by the settlement
Intervene to preserve tenancy and avoid housing separations, and evaluate tenancy issues to extend housing tenure
Ensure health and safety monitoring needs of the TCL members are addressed
Escalate high risk/high visibility and/or complex barriers/needs members who may have SDOH/Behavioral/Physical needs to high-risk committee
Promote customer satisfaction through ongoing communication and timely follow-up on any concerns/issues that include face to face member visits as outlined in DHHS Transition manual
Ensure compliance with all DOJ Settlement requirements including the comprehensive core responsibilities outlined in the DHHS In Reach/Transition and Diversion manual
Distribute surveys to members who are receiving services
Verify that initial service linkage is completed through monitoring of activities in JIVA
Verify members Medicaid and promptly follow up on identified issues.
Monitor and ensure the provision of community services for at least 90 days post transition emphasizing tenancy stability. Resolve any conflict or inadequate care with provider
Follow all TCL policies and procedures
Ensure all documentation (e.g. goals, plans, progress notes, etc.) meet state, organization, and Medicaid requirements
Monitor documentation to ensure that issue/errors are resolved
Follow administrative procedures and effectively manage caseload
Ensure timely documentation into state required TCL platforms
Travel between Alliance offices, attending meetings on behalf of Alliance, participating in Alliance sponsored events, etc. may be required
Travel to meet with members, providers, stakeholders, attend court hearings etc. is required