Transition Coordinator - QP (Vaya's Eastern Counties)

Vaya Health•Oxford, NC

5d•$50,007 - $65,009•Remote

About The Position

The Transition Coordinator QP (TC) is responsible for providing proactive coordination of 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 QP will work with members/recipients in their communities. This position requires access to and use of confidential healthcare information or protected health information (PHI) and requires training and adherence to relevant laws, including HIPAA and state laws. A confidentiality statement must be signed.

Requirements

Bachelor’s degree in a Human Services field and two (2) years of post-bachelor’s degree accumulated experience with the population served, OR a bachelor’s degree in a field other than human services and four (4) years of full-time, post-bachelor's degree accumulated experience with the population served.
Considerable knowledge of the MH/SU/IDD service array provided through the network of Vaya providers.
Proficiency in Microsoft Office products (such as Word, Excel, Outlook, PowerPoint, etc.) and Vaya information system is required.
Must be able to manage an active caseload of member/recipients in transition planning.
Must be able to change the focus of his/her activities to meet changing priorities.
Must be detail oriented, able to organize multiple tasks and priorities, and to effectively manage projects from start to finish.
Must have exceptional interpersonal skills, highly effective communication ability, and the propensity to make prompt independent decisions based upon relevant facts.
Must possess problem solving, negotiation, and conflict resolution skills.
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 reside in North Carolina or within 40 miles of the North Carolina border.
Must maintain residency in North Carolina or within 40 miles of the NC border.

Nice To Haves

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

Responsibilities

Manage an active caseload of member/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 role 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 (e.g., tenancy support, medical health) to ensure they are providing needed services.
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 (e.g., diagnostic assessments, comprehensive clinical assessments, psychological evaluations).
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, including housing, behavioral health services, medical care, financial management, safety and security, and other community supports.
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.
Be 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, requiring brokerage with high-end stakeholders such as hospitals, institutions, and other community stakeholders.
Establish a transition team planning meeting schedule that effectively meets the needs of the particular transition.
Use therapeutic intervention as necessary to evolve and stabilize a member/recipient’s transition experience.
Be available to the transition team, including in-person participation, and ensure move-in logistics have been arranged either directly or in partnership with other teams within the LME/MCO (e.g., Housing specialists).
Ensure follow-along is sufficient to address a person’s clinical and basic needs 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 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.