Care Transition Specialist

2 weeks ago

Indianapolis, Indiana, United States DaMar Staffing Solutions of Indianapolis Full time
Job Overview

Company Overview: A leading healthcare organization based in the Indianapolis Metro area, dedicated to serving over 100 million individuals at various stages of their health journey.

Position Location: This role is primarily remote. Candidates should have a suitable home office setup and be available for occasional in-person team gatherings.

Position Summary: The Long-Term Services and Supports (LTSS) Transition Coordinator plays a crucial role in assisting the LTSS Coordinator (or contracted provider) in implementing the person-centered planning process during care transitions for individuals moving across different care levels.

Key Responsibilities:

  • Facilitate and oversee transitions for individuals relocating between various care environments, including home care, assisted living, and skilled nursing facilities.
  • Work collaboratively with healthcare professionals, social workers, and other relevant parties to ensure a smooth transition experience.
  • Ensure the effectiveness of care plans and adherence to contractual obligations for member outreach, including the coordination and management of individual waivers (such as LTSS/IDD), as well as behavioral and physical health needs.
  • Submit utilization and authorization requests to management, ensuring that documentation aligns with the individual's care plan.
  • Employ tools and a predefined identification process to consult with the primary service coordinator, monitoring the personalized care and support plan (PCSP) when risks are identified regarding the member's LTSS.
  • Manage the non-clinical needs of members with chronic conditions, co-morbidities, and/or disabilities, focusing on cost-effective and efficient utilization of long-term services and supports.
  • Collaborate with the member's chosen care team, which may include caregivers, family members, natural supports, and healthcare providers, to document their short- and long-term service and support goals as directed by the member.
  • Identify members who may benefit from alternative service levels or other waiver programs.
  • May act as a subject matter expert, mentor, or preceptor for new staff, contributing to formal training initiatives and potentially engaging in process improvement activities.
  • Responsible for promptly reporting critical incidents to relevant internal and external entities, including state and county agencies such as Adult Protective Services and Law Enforcement.
  • Provide support and actively participate in appeals, member grievances, hearings, and state audits.

Qualifications:

  • A Bachelor's degree with a minimum of two years of experience in a social work agency, LTSS, healthcare, or the aged and disability sector; or any combination of education and experience that would provide an equivalent background.
  • Preferred experience in managing a community and/or facility-based care management caseload.
  • Experience working remotely is advantageous.
  • Note: Salary range is competitive based on experience, with health insurance and benefits available.

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