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Service Transition Specialist

2 months ago

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

GENERAL OVERVIEW:

The Transition Coordinator QP (TC) plays a crucial role in the proactive orchestration of services for individuals transitioning from institutional settings to home and community-based environments. This position is designed to prepare individuals for discharge and support them during the initial adjustment period following their transition. The TC will engage with individuals within their communities, providing essential support throughout the process.

IMPORTANT NOTE: This role necessitates access to confidential healthcare information, adhering to laws regarding patient confidentiality, including HIPAA and other relevant regulations. The individual will be required to undergo training on these laws and sign a confidentiality agreement as part of their employment with Vaya Health.

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 about their roles and the TC's responsibilities.
  • Adhere to the established policies regarding service boundaries.
Monitoring:
  • Receive monthly updates for transitioned individuals and submit required documentation by deadlines.
  • Work in partnership with community providers to ensure necessary services are delivered.
Transition Coordination:

The Transition Coordinator QP will collaborate 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 developing a transition team and ensuring that planning begins upon admission to the facility.

To facilitate a successful transition, the TC will:
  • Conduct meetings with individuals to review clinical records and ensure necessary assessments are completed.
  • Assist individuals in creating a comprehensive written plan that includes necessary treatment and crisis planning.
  • Engage with individuals and their families to develop a holistic transition plan addressing community support needs.
  • Ensure that discharge planning is person-centered and prioritizes self-determination while considering safety.
  • Coordinate with individuals and their supports to identify and secure community resources necessary for transition.
  • Develop diagnostic impressions to ensure appropriate services are in place during the transition.
  • Utilize motivational interviewing techniques to develop thorough transition plans.
  • Facilitate communication with institutions and community supports involved in the transition.
Diversion Responsibilities:

The TC is responsible for addressing transition needs identified through the Department of Justice diversion process, assisting individuals requiring diversion from institutional settings. This includes collaborating with various stakeholders to ensure organized and timely transitions.

Each transition is unique and may require multiple meetings or ongoing communication to ensure effective planning. The TC will establish a meeting schedule that meets the specific needs of each transition.

Documentation:

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

Collaboration:

The TC will maintain respectful communication with all individuals involved in the transition process, working closely with various departments within Vaya Health to ensure successful planning and implementation.

QUALIFICATIONS:

A Bachelor's degree in a Human Services field with two years of relevant experience, or a degree in another field with four years of experience in the relevant population.

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

Strong interpersonal skills, effective communication, and the ability to make independent decisions are essential. The TC must be detail-oriented, capable of managing multiple tasks, and proficient in Microsoft Office and relevant information systems.

RESIDENCY REQUIREMENT:

Candidates must reside in North Carolina or within 40 miles of the state border.

SALARY: Compensation will be based on qualifications and experience. This position is non-exempt and eligible for overtime.

APPLICATION PROCESS: Vaya Health is an equal opportunity employer.