Transition Coordinator - LP (Buncombe/McDowell/Caldwell/Burke)

Vaya Health • Marion, NC

128d

About The Position

The Transition Coordinator LP (TC) is responsible for providing proactive intervention and coordination services to persons residing in or being diverted from institutionalized settings prior to their transition to home and community based services. These services prepare members/recipients for discharge and assist during adjustment period immediately following discharge from an institution. This is a mobile position with work done in a variety of locations. The Transition Coordinator LP will work with members/recipients in their communities. Note: 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 with clinical licensure (LCSW, LCMHC, LPA, or LMFT) required.
• Two (2) years of post-human services bachelor’s degree with accumulated experience with the population served or four (4) years of full-time, post non-human services bachelor's degree with accumulated experience with the population served.
• High level of diplomacy and discretion to effectively negotiate and resolve issues.
• Exceptional interpersonal skills and highly effective communication ability.
• Proficiency in Microsoft Office products (such as Word, Excel, Outlook, PowerPoint, etc.) and Vaya information system.

Nice To Haves

• Considerable knowledge of the MH/SU/IDD service array provided through the network of Vaya providers.
• Additional knowledge in Vaya Medicaid B and C waivers and accreditation.

Responsibilities

• Manage an active caseload of members/recipients in transition planning.
• Work with manager to create a yearly target number of successful transitions based on state benchmark.
• Ensure that the Pre-Quality of Life survey is completed prior to lease signing date.
• Educate providers of tenancy support about their respective roles and responsibilities and of the TC's roles and restrictions.
• Adhere to boundaries within the In Reach, Transition, Diversion policy and do not provide services or supports outside of the scope of work.
• Ensure that monthly updates are received for transitioned members/recipients and submit auditing tool by deadline.
• Work alongside community providers (i.e., tenancy support, medical health, etc.) to ensure they are providing needed services.
• Be available for staffing and clinical consultation to other team members as needed.
• Meet with the member/recipient, conduct clinical record review, and ensure completion of necessary assessments as needed.
• Assist the member/recipient in developing an effective written plan which will include linkage to necessary treatment and crisis planning.
• Network with the member/recipient and the member/recipient’s family and supports to develop a thoughtful, organized, holistic transition plan.
• Ensure discharge/transition planning is developed and implemented through person-centered planning processes.
• Coordinate with the member/recipient, his/her family and supports to identify and secure the Community resources necessary to transition.
• Develop diagnostic impression prior to linkage of services to ensure clinically appropriate services are in place during transition.
• Use motivational interviewing techniques to ensure a thorough North Carolina Person Centered Plan (NCPCP) is developed.
• Foster communication with institutions, provider agencies, and other community and natural supports that will be involved in the transition.
• Assume responsibility for being responsive to the transition needs identified through the Department of Justice diversion process.
• Establish a transition team planning meeting schedule that effectively meets the needs of the particular transition.
• Be available to the transition team, including in person participation and ensure move-in logistics have been arranged.
• Document the transition process for each member/recipient clearly and concisely.
• Maintain ongoing, respectful communication with all members/recipients involved in the transition process.

Benefits

• Salary depending on qualifications & experience.
• Exempt position not eligible for overtime compensation.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Master's degree