MFP Transition Coordinator

3 weeks ago

Port Wentworth, Georgia, United States Vaya Health Full time
About the Role

Vaya Health is seeking a highly skilled and dedicated Transition Coordinator to join our team. As a key member of our community support services, you will play a critical role in facilitating the transition of eligible older adults and adults with physical disabilities from long-term care facilities to community-based living arrangements.

Key Responsibilities
  • Transition Coordination: Collaborate with transition partners to ensure the quality, efficiency, and integrity of the transition process for each MFP participant.
  • Lead the transition team, assigning tasks, monitoring completion, reporting status changes, and reassessing as needed.
  • Secure and coordinate resources and supports to enable participants to live as independently as possible in the community.
  • Ensure critical benefits and supports, such as Social Security payments, SNAP benefits, public transportation, utility services, and other benefits, are in place prior to transition.
  • Maintain required documentation for each transition, including transition needs budget, preliminary and final transition plan, MFP Transition Checklist, and monthly database updates.
Post-Transition Support
  • Provide follow-up support in-person and virtually for a minimum of one year post-transition.
  • Continue monitoring each MFP participant's budget for up to one year post-discharge to ensure as many needs as possible are met using available funds.
  • Collaborate with Long-Term Care Ombudsman, Local Contact Agencies, and other community organizations to provide outreach about transition services.
Communication and Collaboration
  • Participate in multiple monthly conference calls with other transition coordinators, Division of Vocational Rehabilitation (DVR), other transition coordination partners, and MFP staff.
  • Work closely with other Vaya staff, including managers, supervisors, care coordination, hospital liaisons, and other departments necessary for successful transition planning.
Documentation and Reporting
  • Document the in-reach and transition progress accurately and clearly to inform local, state, and federal agencies.
  • Ensure all contacts and interventions with participants are documented in the consumer's administrative health record.
  • Ensure that all required documentation and reports are submitted to manager prior to deadlines.
Requirements
  • Bachelor's degree in a human services or related field, and two years related experience.
  • OR Master's degree in a human services or related field, and at least one year of related experience.
Physical Requirements
  • Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
  • Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
  • Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
  • Mental concentration is required in all aspects of work.
Residency Requirement

This position is required to reside in North Carolina or within 40 miles of the North Carolina border.

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