Care Transition Specialist
2 days ago
We are seeking a highly skilled Care Transition Specialist to join our team at Arkansas Foundation for Medical Care. As a Care Transition Specialist, you will play a critical role in supporting the Hospital to Home Program in a specific service area.
Key Responsibilities:- Participate in discharge planning processes with the AFMC Clinical Case Manager.
- Coordinate eligibility documentation needs between the program participant and Eligibility Specialist based on requests from the Eligibility Specialist.
- Meet with the AFMC Clinical Case Manager to review the home services plan and schedule the initial in-home visit.
- Conduct the home visit and note any additional necessary non-clinical services needed for participants success at their home.
- Meet with the AFMC Clinical Case Manager to discuss additional findings and wait for the home services plan to be finalized and approved by one of the following: the Clinical Lead - Nursing, Clinical Lead - Physician, or the Project Manager.
- Coordinate clinical and non-clinical services for each participant based on the approved home services plan.
- Assist participants with making appointments and coordinating services or community resources to support the participant's success for reaching scheduled appointments.
- Provide reminder calls/texts and follow up to ensure community members get to their appointments.
- Help participants access transportation or other assistance to ensure they overcome barriers to making their appointments.
- Assist participants in their homes, community, or clinic setting.
- Provide care coordination and care transitions for participants under the direction of the clinical case manager.
- Assist participant with enrollment in programs and benefits for which they are eligible under the direction of the eligibility specialist.
- Utilize the AFMC company credit card to purchase non-clinical or clinical service purchases based on Hospital to Home policies and procedures.
- Document all activities in the AFMC Salesforce platform.
- Attend all meetings with AFMC staff for planning and weekly updates.
- Document hours to appropriate charge codes in AFMC or partner organization timesheet software.
- Follow mileage reimbursement policies and procedures for each home visit.
- Participate in all required company training including but not limited to IT and privacy and security trainings.
- Make contact with each participant at least one time per week while they are enrolled in the program or until they are enrolled in a Medicaid waver.
- Within 72 hours of acceptance, complete a needs assessment for the participant.
- Advocate for participants, ensuring their voices are heard and their rights and responsibilities are respected throughout the transition process.
- Provide support, information, guidance, and education to participants and their families.
- Identify each participant's needs and prioritize the needs based on most likely to help keep them in the setting of their choosing.
- Coordinate and facilitate the delivery of services, ensuring the smooth transition between different levels of care and providers. This may include arranging appointments, submitting, or requesting referrals, and coordinating follow-up visits.
- Provide application assistance for Medicaid, HCBS Waivers, Supplemental Nutrition Assistance Program (SNAP), and other services.
- Monitor services being provided to ensure that the services properly address the participant's unmet needs.
- Coordinate social support for the participants (family, neighbors, friends, community centers, church, etc.).
- Educate participants on available home and community-based resources and the resources available to support them in the setting of their choice.
- Maintain accurate and up-to-date documentation of all transition-related activities, assessments, plans, and services provided.
- Review provider invoices for services rendered to participants.
- Ensure all activities address designated performance goals, the appropriate target audience, and are performed within designated time frame.
- Adhere to format, content, and style guidelines, giving consideration to usability and ensuring accuracy, consistency, and quality. Maintain editorial/communication mission.
- Communicate needs and requests to other team members as appropriate.
- Follow AFMC, state and federal protocols regarding data confidentiality/security and HIPAA compliance.
- Additional duties as assigned.
- Intermediate skill level with MS Office (Word, Excel, Outlook, and PowerPoint).
- Previous skill set in working with Adobe Creative Suite Design software package.
- Ability to prepare files for electronic or physical transport external locations.
- Proficiency in prepress practices and procedures. Knowledge of color management practices, though not required, is preferred.
- Type 40 wpm.
- Exceptional skills in business English and spelling are required.
- Ability to maintain confidentiality.
- Strong oral and written communication skills.
- Creativity.
- Customer service.
- Ability to meet deadlines.
- Attention to detail.
- Flexibility.
- Ability to work independently.
- Initiative.
- Ability to relate professionally and positively with staff, business partners, customers, constituents, recipients, and the public.
- Ability to multitask.
- Ability to prioritize.
- Strong organizational skills.
- Problem solving skills.
- Professionalism.
- Project management skills.
- Strong public speaking skills.
- Teamwork.
- Time management skills.
Physical and Sensory Requirements:
Mobility, reaching, bending, lifting, grasping, ability to read and write, ability to communicate with personnel, ability to remain calm under stress.
Must be able to lift and transport 25 pounds. Must be capable of performing the essential job functions of this job, with or without reasonable accommodations.
Education:
Required: High School Diploma or equivalent.
Desired: Completed Community Health Work training.
Experience:
Required: One (1) year health care or social services experience.
Internet Requirements:
Reliable, high-speed wireless internet service (Wi-Fi)
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