Transition Specialist

2 weeks ago

Wilmington, North Carolina, United States Vaya Health Full time
LOCATION: Remote – candidates must reside in or near specified counties in North Carolina. This role will cater to these regions.

GENERAL OVERVIEW

The Transition Specialist is tasked with delivering proactive intervention and coordination services to individuals transitioning from institutional settings to home and community-based services. These services are designed to prepare clients for discharge and support them during the adjustment period immediately following their exit from an institution. This is a mobile role requiring work in various locations, engaging with clients within their communities.

CONFIDENTIALITY NOTICE: This position necessitates access to confidential healthcare information or protected health information (PHI) as outlined in laws governing patient confidentiality, including federal HIPAA regulations and state laws. The individual in this role will be required to undergo training regarding these laws and must adhere to them as a Vaya Health employee. A confidentiality agreement will also be required.

KEY RESPONSIBILITIES

Transition Planning
  • Manage an active caseload of clients involved in transition planning.
  • Collaborate with management to establish annual targets for successful transitions based on state benchmarks.
  • Ensure completion of the Pre-Quality of Life survey prior to lease signing.
  • Educate tenancy support providers about their roles and responsibilities, as well as the limitations of the Transition Specialist's role.
  • Adhere to established boundaries within the In Reach, Transition, and Diversion policies, refraining from providing services outside the defined scope.
Monitoring
  • Ensure timely receipt of monthly updates for transitioned clients and submit auditing tools by deadlines.
  • Collaborate with community providers (e.g., tenancy support, medical health) to ensure necessary services are delivered.
  • Be available for staffing and clinical consultations with team members as required.
Leading the Transition Process

The Transition Specialist will work closely with the Transition Coordinator to ensure that any client wishing to move to a more inclusive setting receives clinically appropriate behavioral health services and support. This includes collaboration with In Reach staff, care management, and other departments to initiate transition planning upon admission to the facility.

To facilitate a successful transition, the Transition Specialist will:
  • Engage with the client, review clinical records, and ensure necessary assessments are completed.
  • Assist the client in developing a comprehensive written plan that includes linkage to essential treatment and crisis planning for independent living.
  • Network with the client, their family, and support systems to create a holistic transition plan addressing community-based support needs.
  • Ensure that discharge planning is person-centered, allowing the client to play a primary role while considering their safety and well-being.
  • Coordinate with the client and their support network to identify and secure community resources necessary for a successful transition.
  • Develop diagnostic impressions prior to linking services to ensure appropriate clinical support during the transition.
  • Utilize motivational interviewing techniques to ensure a thorough North Carolina Person Centered Plan (NCPCP) is developed.
  • Foster communication with institutions, provider agencies, and community supports involved in the transition.
Diversion Responsibilities

The Transition Specialist is responsible for addressing transition needs identified through the Department of Justice diversion process, assisting clients requiring diversion from institutional settings. This involves collaboration with key stakeholders such as hospitals and community organizations.

Each transition experience is unique and may necessitate multiple meetings or ongoing communication to ensure an organized and timely process. In partnership with the client and transition team, the Transition Specialist will establish a meeting schedule that effectively meets the needs of the transition. Therapeutic interventions may be employed to support and stabilize the client's transition experience.

Follow-up support is also a critical component of the transition process, ensuring that the client's clinical and basic needs are met promptly to prevent loss of essential services or housing.

Documentation

The Transition Specialist is responsible for maintaining clear and concise documentation of the transition process for each client. This documentation will inform local organizations, state, and federal entities. All interactions and interventions will be recorded in the client's administrative health record.

Collaboration

The Transition Specialist will maintain ongoing, respectful communication with all clients involved in the transition process. They will work closely with In Reach staff, care coordination, hospital liaisons, and other departments to create and implement effective transition planning. The Transition Specialist will also engage in educational efforts with clients, families, providers, and stakeholders related to community living transitions.

ADDITIONAL RESPONSIBILITIES

Other duties may be assigned as necessary.

SKILLS & QUALIFICATIONS

Exceptional diplomacy and discretion are required to effectively negotiate and resolve issues independently. Strong interpersonal skills, effective communication abilities, and prompt decision-making based on relevant information are essential. Problem-solving, negotiation, and conflict resolution skills are crucial for balancing the needs of both internal and external stakeholders.

The Transition Specialist must possess a comprehensive understanding of the Diagnostic and Statistical Manual of Mental Disorders (current version) and have substantial knowledge of the mental health, substance use, and intellectual/developmental disability service array provided through Vaya's network. Familiarity with Vaya Medicaid waivers and accreditation processes is advantageous.

Attention to detail, the ability to manage multiple tasks and priorities, and effective project management skills are required. The role demands adaptability to changing priorities and mandates within the department. Proficiency in Microsoft Office applications and Vaya's information systems is necessary.

EDUCATIONAL REQUIREMENTS

A Master's degree in a Human Services field with clinical licensure (LCSW, LCMHC, LPA, or LMFT) and two years of relevant experience, or four years of full-time experience in a related field.

LICENSURE/CERTIFICATION

Must hold a Master's-level clinical license or provisional license in social work, mental health counseling, psychological association, marriage and family therapy, or nursing.

PHYSICAL DEMANDS
  • Close visual acuity for document preparation and analysis, computer use, and extensive reading.
  • Physical activities include crouching, reaching, walking, talking, hearing, and repetitive hand motions.
  • Sedentary work with lifting requirements up to 10 pounds and prolonged sitting.
  • Mental concentration is essential in all aspects of the role.
RESIDENCY REQUIREMENT: Candidates must reside in North Carolina or within 40 miles of the state border.

SALARY: Commensurate with qualifications and experience. This position is exempt from overtime compensation.

APPLICATION PROCESS: Vaya Health accepts online applications through our Career Center.

Vaya Health is an equal opportunity employer.

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