Transitions Health Management Coordinator; NC

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Full Time Social Services DAVIDSON, NC, US 1 Attachments

2 days ago Requisition

Competitive Compensation & Benefits Package!

Position eligible for –

• Annual incentive bonus plan
• Medical, dental, and vision insurance with low deductible/low cost health plan
• Generous vacation and sick time accrual
• 12 paid holidays
• State Retirement (pension plan)
• 401(k) Plan with employer match
• Company paid life and disability insurance
• Wellness Programs
• Public Service Loan Forgiveness Qualifying Employer

See attachment for additional details.

Office

Location:

Available for Gastonia, Davie, Davidson, Forsyth NC locations

Projected Hiring Range: Depending on Experience

Closing Date:
Open Until Filled

Primary Purpose of Position:

The purpose of this position is to ensure that members receive coordination and continuity of care as they transition between different settings or levels of care. This Includes but is not limited to; acute hospitals, EDs, skilled nursing homes, facility-based crisis, assisted living facilities and jail/prisons. This position will also assist members in their efforts to improve their quality of life across the Physical Health, Behavioral Health, Intellectual/developmental Disability (IDD), Traumatic Brain Injury (TBI), and Pharmacy domains to help prevent hospital readmission.

The Transitions Health Management Coordinator works with the member, Tailored Care Manager, and care team to identify and alleviate inappropriate levels of care or gaps in services. Travel is an essential function of this position.

Role and Responsibilities:

The Transitions Health Management Coordinator is responsible for (though not limited to):

• Support members transitioning from inpatient settings to the appropriate lower or lateral level of care
• Provide subject matter expertise, within scope, regarding member’s physical and/or behavioral health to support the development and delivery of a whole person approach to Care Management
• Collaboratively works with other Partners team members, behavioral health providers, primary care physicians, specialty care providers and other community partners and stakeholders to support members in their home communities
• Conducts on site visit with member during their stay in residential or inpatient settings (e.g., acute, ED and long–term stay facilities)
• Conduct outreach to the member’s providers.
• Obtain a copy of the discharge plan and review the discharge plan with the member, facility staff and Tailored Care Manager.
• Facilitate clinical handoffs.
• Assist the member in obtaining needed medications prior to discharge, ensure an appropriate care team member conducts medication reconciliation/management and support medication adherence.
• Develop a ninety (90) day post-discharge transition plan prior to discharge from residential or inpatient settings, in consultation with the member, facility staff and the member’s care team, that outlines how the member will maintain, or access needed services and supports, transition to the new care setting, and integrate into the community.
• Communicate and provide education to the member and the member’s caregivers and providers to promote understanding of the ninety (90) day post-discharge transition plan.(Assist with scheduling of transportation, in-home services, and follow-up outpatient visits with appropriate providers within a maximum of seven (7) Calendar Days post-discharge, unless required within a shorter timeframe.
• Ensures follow-up with the member within forty-eight (48) hours of discharge.
• Appropriately escalates high risk/high visibility and/or complex barriers/needs members who may have difficulty transitioning out of the facility in a timely manner to supervisors. High risk can involve Health and Safety of a member, staff, or organizational risk
• Review cases with clinical complexity with direct supervisor and follow escalation protocols to ensure timely engagement from members or our Medical Team and Provider Networks
• Obtain information releases that will improve…