Transitions Health Management Coordinator (NC)

Partners Behavioral Health Management•Gastonia, NC

16d

About The Position

The purpose of this position is to ensure that members receive coordination and continuity of care as they transition between different settings or levels of care. This Includes but is not limited to; acute hospitals, EDs, skilled nursing homes, facility-based crisis, assisted living facilities and jail/prisons. This position will also assist members in their efforts to improve their quality of life across the Physical Health, Behavioral Health, Intellectual/developmental Disability (IDD), Traumatic Brain Injury (TBI), and Pharmacy domains to help prevent hospital readmission. The Transitions Health Management Coordinator works with the member, Tailored Care Manager, and care team to identify and alleviate inappropriate levels of care or gaps in services. Travel is an essential function of this position.

Requirements

Extensive understanding of the Diagnostic and Statistical Manual of Mental Disorders (current version)
Considerable knowledge of the MHSU/IDD service array provided through the network of the LME/MCO’s providers
Knowledge of LME/MCO’s implementation of the 1915(b/c) waivers and accreditation
Highly skilled at assuring that both long and short-range goals and needs of the individual are addressed and updated, while assuring through monitoring activities that service implementation occurs appropriately
Exceptional interpersonal and communication skills
Excellent computer skills including proficiency in Microsoft Office products (Word, Excel, Outlook, and PowerPoint)
Excellent problem solving, negotiation, arbitration, and conflict resolution skills
Detail-oriented, able to organize multiple tasks and priorities and effectively manage projects from start to finish
Ability to make prompt independent decisions based upon relevant facts, to establish rapport and maintain effective working relationships
Ability to change the focus of his/her activities to meet changing priorities
A high level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance
Must reside in North Carolina.
Must have ability to travel as needed to perform the job duties
Bachelor's degree in a human service field with two years of full-time, post-bachelor's degree experience with the population served
Bachelor's degree in a field other than human services with four years of full-time, post-bachelor's degree experience with the population served
Master’s degree in a human service field and one year of full-time, post-graduate degree experience with the population served

Nice To Haves

Licensed to practice as a Registered Nurse in North Carolina and two years of experience in nursing; care management/care coordination; care transition experience.
Experience in collaborative care.

Responsibilities

Support members transitioning from inpatient settings to the appropriate lower or lateral level of care
Provide subject matter expertise, within scope, regarding member’s physical and/or behavioral health to support the development and delivery of a whole person approach to Care Management 
Collaboratively works with other Partners team members, behavioral health providers, primary care physicians, specialty care providers and other community partners and stakeholders to support members in their home communities
Conducts on site visit with member during their stay in residential or inpatient settings (e.g., acute, ED and long–term stay facilities) 
Conduct outreach to the member’s providers.
Obtain a copy of the discharge plan and review the discharge plan with the member, facility staff and Tailored Care Manager.
Facilitate clinical handoffs.
Assist the member in obtaining needed medications prior to discharge, ensure an appropriate care team member conducts medication reconciliation/management and support medication adherence.
Develop a ninety (90) day post-discharge transition plan prior to discharge from residential or inpatient settings, in consultation with the member, facility staff and the member’s care team, that outlines how the member will maintain, or access needed services and supports, transition to the new care setting, and integrate into the community.
Communicate and provide education to the member and the member’s caregivers and providers to promote understanding of the ninety (90) day post-discharge transition plan.(Assist with scheduling of transportation, in-home services, and follow-up outpatient visits with appropriate providers within a maximum of seven (7) Calendar Days post-discharge, unless required within a shorter timeframe.
Ensures follow-up with the member within forty-eight (48) hours of discharge.
Appropriately escalate high risk/high visibility and/or complex barriers/needs members who may have difficulty transitioning out of the facility in a timely manner to supervisors. High risk can involve Health and Safety of a member, staff, or organizational risk 
Review cases with clinical complexity with direct supervisor and follow escalation protocols to ensure timely engagement from members or our Medical Team and Provider Networks 
Obtain information releases that will improve care management activities on behalf of the member