Caldwell Co, NC)

Vaya Health•Asheville, NC

16h•$62,994 - $81,892•Remote

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. 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 and 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.
Master-level fully Licensed or provisionally Licensed Clinical Social Worker (LCSW), fully Licensed or provisionally Licensed Clinical Mental Health Counselor (LCMHC), fully Licensed or provisionally Licensed Psychological Associate (LPA), fully Licensed or provisionally Licensed Marriage and Family Therapist (LMFT) or licensure as a Registered Nurse (RN)
High level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance.
Exceptional interpersonal skills, highly effective communication ability, and the propensity to make prompt independent decisions based upon relevant facts.
Problem solving, negotiation, arbitration and conflict resolution skills are essential to balance the needs of both internal and external customers.
Highly skilled at shifting between macro and micro level planning, maintaining both the big picture and seeing that the details are covered.
Extensive understanding of the Diagnostic and Statistical Manual of Mental Disorders (current version).
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.
Proficiency in Microsoft Office products (such as Word, Excel, Outlook, PowerPoint, etc.) and Vaya information system is required.

Nice To Haves

Knowledge in Vaya Medicaid B and C waivers and accreditation is helpful.

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 does 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.
Work alongside the Transition Coordinator LP to ensure that any member/recipient who wishes to move to a more inclusive setting, from the adult care home or state psychiatric hospital, is provided with clinically indicated and appropriate behavioral health services and supports and In Reach staff, care management, and other Vaya departments necessary to ensure transition/discharge planning begins at admission to the facility.
Assist in developing the transition team.
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 to enable the member/recipient to live independently in an integrated community setting.
Network with the member/recipient and the member/recipient’s family and supports to develop a thoughtful, organized, holistic transition plan that addresses his/her community-based support needs.
Ensure discharge/transition planning is developed and implemented through person-centered planning processes in which the member/recipient has a primary role and is based on the principle of self-determination while considering safety and well-being.
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, ensuring a member/recipient requiring diversion from an Adult Care Home via the Referral Screening Verification Process (RSVP).
Assist the member/recipient through the transition planning 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 will ensure move-in logistics have been arranged either directly or in partnership with other teams within the LME/MCO (i.e., Housing specialists).
Ensure that a person’s clinical and basic needs are identified and addressed in a timely way that ensures the member/recipient does not lose critical services or housing.
Provide clear and concise documentation of the transition process for each member/recipient.
Maintain ongoing, respectful communication with all members/recipients involved in the transition process.
Work closely with the In Reach staff, care coordination, hospital liaisons and other Vaya departments necessary to create, implement and fulfill successful transition planning with members/recipients.
Be involved in education with members/recipients, families, providers, and stakeholders associated with Transitions to Community Living.
Perform other duties as assigned.