Transition & Assessment Coordinator, Mid

Acentra Health, LLC•UNAVAILABLE, Pennsylvania

About The Position

Acentra Health is looking for a Transition & Assessment Coordinator, Mid to join our growing team. The Transition and Assessment Coordinator is responsible for coordinating and facilitates Specialized Services (SS), Nursing Home Transition (NHT), and Needs Assessment activities in alignment with contractual requirements to support positive participant outcomes and a high-quality customer experience. The role also serves as a resource on OLTL requirements and updates and functions as an educational liaison to nursing facility staff regarding SS, NHT, and PCEDME services.

Requirements

Bachelor’s degree in Human Services, Social Work, Psychology or a related field.
A minimum of 3-5 years of experience working directly with individuals requiring long-term services and supports (LTSS).
Intermediate proficiency in Microsoft Office products.
Strong organizational and time management skills.
Ability to work independently, prioritize tasks, manage workload, and meet tight deadlines in a fast-paced environment.

Nice To Haves

Extensive experience working with the ID/A and geriatric populations.
Strong familiarity with ODP waiver programs and OLTL services and supports.
Preferred knowledge and experience working with nursing facilities, service providers and other stakeholders.
Demonstrated problem-solving skills for complex issues and application of knowledge to process improvement and ensure issue resolution.
Proven ability to conduct assessments and engage participants effectively through in-person, telephonic, and virtual platforms.
Professional demeanor with strong interviewing, communication and relationship-building skills, including the ability to engage effectively with diverse audiences in both individual and group settings.
Proficient in developing written summaries, participant documentation, and stakeholder communications while ensuring accuracy and compliance with program requirements.
Bilingual proficiency in English/Spanish is a plus.

Responsibilities

Utilize independent judgment, critical thinking, and knowledge of the needs of individuals with intellectual disabilities and/or autism to conduct comprehensive Needs Assessments and support person-centered service planning as identified by ODP.
Provide Specialized Services (SS) in accordance with contractual requirements, program standards, and established performance expectations as determined by OLTL.
Facilitate Nursing Home Transition (NHT) activities by identifying, coordinating, and securing community housing, services, resources and supports to promote successful community integration and long-term stability for eligible participants.
Develop and maintain registry of community-based resources, housing options, and service networks to support successful participant outcomes and community integration across service area.
Complete recommendations, documentation, and follow-up for individuals needing Exceptional Durable Medical Equipment (EDME) in accordance with OLTL requirements.
Provide Preadmission Screening and Resident Review (PASRR) determination explanations for individuals with Level II PASRRs as referred by OLTL.
Provide education and guidance related to SS/NHT programs to participants, nursing facilities, and community partners as appropriate.
Establish and maintain positive working relationships with participants, families, supports coordinators, providers, nursing facility staff, community organizations, and other stakeholders to facilitate service delivery and positive outcomes.
Resolve participant, provider, and stakeholder concerns through effective communication, problem-solving, and appropriate utilization of available resources.
Manage assigned workload and scheduling responsibilities to ensure timely completion of assessments, transition activities, documentation, and follow-up activities in accordance with contractual requirements.
Maintain accurate, timely, and compliant documentation, ensuring adherence to all contractual requirements, regulatory standards, and organizational policies, including HIPAA Privacy and Security requirements.
Remain current on applicable OLTL, ODP, and other regulatory requirements, program updates, and best practices impacting service delivery.
Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.