The Transition Coordinator II provides Transitional Care Management and Physical Health Consultation for members with physical and/or behavioral health needs in Acute Care facilities, State Operated Developmental Centers, and Justice System settings. For Transition Coordinator II’s assigned to a facility, there will be active and onsite participation in discharge planning beginning with admission.
This position will be a primarily remote. However, the successful candidate must reside in North Carolina and be willing to come onsite for critical business meetings as needed; they will also be required to serve members onsite at local psychiatric inpatient hospitals, a minimum of 2 days a week.
Responsibilities & Duties
Provide Care Team Support
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
Work collaboratively with other Alliance staff, behavioral health providers, primary care physicians, specialty care providers and other community partners and stakeholders to support members in their home communities
Core Transitional Care Management Functions
Conducts on site visit the member during their stay in an
institution (e.g., acute, subacute 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 and facility staff.
Facilitate clinical handoffs.
Refer and assist members in accessing needed social services and supports identified as part of the transitional care management process, including access to housing.
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 their
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 follows up with the member within forty-eight (48) hours of
discharge.
Conduct In reach and transitions for Special Populations receiving care in Inpatient settings (State Hospitals, PRTF’s)
Monitoring/Coordination
Appropriately escalate 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 care management activities on behalf of the member
Reports care quality concerns to Quality Management as needed
Documentation
Ensure all clinical documentation (e.g. goals, plans, progress notes, etc.) meet state, agency, and Medicaid requirements
Ensure accuracy and quality of Warm Hand Off summaries
Follow administrative procedures and effectively manages caseload
Data
Review, validate and interpret risk stratification data and population health groups and recommend changes or adjustments to care management approach as needed
Utilize data to analyze needs of the members we serve, guide staff training development, identify resource needs and consistency of workflow implementation across disciplines
Minimum Requirements
Education & Experience
Graduation from an accredited school of Nursing and three (3) years of full-time, post degree experience providing care management, case management, care coordination, discharge planning, or utilization management to members with Behavioral Health and Physical Health conditions in a behavioral health, medical, or managed care setting. Must have a valid, active RN license in North Carolina.
Or
Master’s degree from an accredited college or university in Human Services or related field and at least two (2) years of full-time, post graduate degree experience providing care management, case management, care coordination, discharge planning, or utilization management to members with Behavioral Health and Physical Health conditions in a behavioral health, medical, or managed care setting. Must have a valid, active clinical license (LCSW, LMFT, LCAS, LCMHC, LPA) in North Carolina.
Preferred: NACCM, NADD-Specialist, Health Education Specialist, and/or CBIS certification preferred.
Knowledge, Skills, & Abilities
A demonstrated Knowledge of the assessment and treatment of mental health, substance abuse, intellectual and developmental disabilities,
Knowledge of legal, waiver, accreditation standards and program practices/requirements.
Knowledge of the Alliance Health service benefit plans and network providers.
Person Centered Thinking/planning
The employee must be detail oriented,
Ability to independently organize multiple tasks, priorities, and to effectively manage an assigned caseload under pressure of deadlines.
Exceptional interpersonal skills, highly effective communication ability,
Ability to make prompt independent decisions based upon relevant facts and established processes.
Problem solving, negotiation and conflict resolution skills
Proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) is required.
Want to learn more about what it's like work as part of the Care Management Team? Click on our video to learn more:https://youtu.be/1GZOBFx61QU
Salary Range
$66,240.00 to $86,112.00/Annually
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.
An excellent fringe benefit package accompanies the salary, which includes:
Medical, Dental, Vision, Life, Long Term Disability
Generous retirement savings plan
Flexible work schedules including hybrid/remote options
Paid time off including vacation, sick leave, holiday, management leave
