Service Transition Specialist

2 weeks ago

Wilmington, North Carolina, United States Vaya Health Full time
LOCATION: Remote – must reside in or near specified counties in North Carolina.

GENERAL OVERVIEW:

The Transition Coordinator QP (TC) plays a pivotal role in the proactive management of services for individuals transitioning from institutional settings to home and community-based services. This position is essential in preparing individuals for discharge and providing support during the adjustment period that follows. The role requires mobility and engagement with members/recipients in their respective communities.

IMPORTANT NOTE: This role necessitates access to confidential healthcare information, requiring adherence to laws governing patient confidentiality, including HIPAA and other relevant regulations. The individual in this position will undergo training regarding these laws and will be required to sign a confidentiality agreement.

KEY RESPONSIBILITIES:

Transition Planning:
  • Manage an active caseload of individuals in transition planning.
  • Collaborate with management to establish annual targets for successful transitions.
  • Ensure completion of the Pre-Quality of Life survey prior to lease signing.
  • Educate service providers on their roles and the TC's responsibilities.
  • Adhere to established boundaries within transition policies.
Monitoring:
  • Collect monthly updates for transitioned individuals and submit required documentation by deadlines.
  • Collaborate with community providers to ensure necessary services are delivered.
Transition Coordination:

The Transition Coordinator QP will work in tandem with the Transition Coordinator LP to ensure that individuals wishing to move to more inclusive settings receive appropriate behavioral health services and supports. This includes initiating transition planning upon admission to the facility and assisting in the formation of the transition team.

To ensure a successful transition, the Transition Coordinator QP will:
  • Conduct meetings with individuals, review clinical records, and complete necessary assessments.
  • Assist in developing a comprehensive written plan that links to essential treatment and crisis management resources.
  • Engage with individuals and their families to create a holistic transition plan addressing community support needs.
  • Facilitate person-centered planning processes that prioritize the individual's role and self-determination.
  • Identify and secure community resources necessary for successful transitions.
  • Ensure clinically appropriate services are in place during the transition.
  • Utilize motivational interviewing techniques to develop thorough transition plans.
  • Foster communication with institutions and community supports involved in the transition.
Diversion Responsibilities:

The Transition Coordinator QP will respond to transition needs identified through the Department of Justice diversion process, assisting individuals through the transition planning process and coordinating with key stakeholders.

Each transition experience is unique, requiring tailored communication and planning to ensure organized and timely transitions. The Transition Coordinator will establish a meeting schedule that meets the specific needs of each transition, utilizing therapeutic interventions as necessary.

Follow-up support is critical to ensure that individuals' clinical and basic needs are met promptly, preventing loss of essential services or housing.

Documentation:

The Transition Coordinator QP is responsible for thorough documentation of the transition process for each individual, ensuring compliance with local, state, and federal regulations. All interactions and interventions will be recorded in the individual's administrative health record.

Collaboration:

Ongoing communication with all parties involved in the transition process is essential. The Transition Coordinator QP will work closely with various departments within Vaya Health to create and implement effective transition plans.

QUALIFICATIONS:

A Bachelor’s degree in a Human Services field and two years of relevant experience, or a Bachelor’s degree in another field with four years of experience in a related area.

PHYSICAL REQUIREMENTS:
  • Close visual acuity for document preparation and analysis.
  • Physical activities include walking, talking, and repetitive motions.
  • Sedentary work with occasional lifting of up to 10 pounds.
  • Mental concentration is required in all aspects of work.
SKILLS & ABILITIES:

Exceptional interpersonal skills, effective communication, and the ability to make independent decisions are essential. Strong problem-solving and conflict resolution skills are necessary to balance the needs of various stakeholders. The Transition Coordinator QP must be detail-oriented, capable of managing multiple tasks, and proficient in Microsoft Office and relevant information systems.

RESIDENCY REQUIREMENT:

This position requires residency in North Carolina or within 40 miles of the state border.

SALARY: Based on qualifications and experience. This position is non-exempt and eligible for overtime compensation.

APPLICATION PROCESS:

Vaya Health is an equal opportunity employer.

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