Transition Care Coordinator-Virginia Resident In-Field, Home-based, & Telephonic (46669)

The Transitional Care Coordinator (TCC) is key to ensuring safe and effective transfers in the movement of patients across the care continuum, serving as the bridge between the professional staff in a care setting (e.g. hospital) and the patient and/or family. The TCC will assist the care manager or care coordinator in the transition of Medicaid Managed Care Members through in-patient hospitalizations. Assist with Member/family/facility to develop or modify Care Plan, transition assessments, and ensure follow-up appointments are made to provide a safe and successful transition/discharge back to the community-based setting or lower level of care. Transitional Care Coordinator must be located in Virginia while performing job responsibilities. Requires bachelor’s degree in the health and human services field, LMHP, RN/LPN, QMHP, LMSW, LBSW, MSW or BSW with at least one (1) year experience serving Virginia’s Medicaid LTSS program population and/or the Cardinal Care Contract for care management.Salary:  $50,000/yr-$55,000/yr.  Location:  Hampon/Newport News, Virginia

POSITION RESPONSIBILITIES:

• TCC will provide specialized support for Members, with a focus on addressing health related social needs (HRSNs), providing psychosocial support, and ensuring Member’s service needs are met.
• TCC may conduct telephonic hospital inquiries with Care Managers, Utilization Managers, Discharge Planners etc. and provide information and guidance to the admitted patient and/or family for acceptance of the transitional care support program for members identified and referred by the Managed Care Organization (MCO).
• TCC will conduct telephonic home visits and follow-up phone calls to assist Members with transitioning between levels of care resulting from in-patient hospitalizations and report accurate and timely documentation on each referred patient in database system(s) including complete and concise activity entry notes within the guidelines of the Transitional Care Support Program. If member is not reached by phone after 2 days/attempts, a drive-by to the address on record is required for face to face.
• TCC will assist members who wish to remain in their community-based setting with community resources, services, or equipment needs (i.e. durable medical equipment, adult day health services, etc.).
• TCC may collaborate daily with physicians and in-patient clinical staff on behalf of member.
• TCC will work in partnership with the member, family/power of attorney, facility personnel, primary care provider, primary care manager, care coordinator, DMAS personnel, housing specialists, social workers, or other appropriate stakeholders for safe Member transitions of care.
• Update Member Care Plan.
• Document admission and transition/discharge assessment note in appropriate care management system(s).
• Assists with scheduling of discharge/aftercare appointments and identifies non-clinical supports and the role they serve in the Member’s treatment and aftercare plans.

ESSENTIAL SKILLS AND EXPERIENCE:

• Rely on extensive experience and judgment to plan and accomplish goals. Performs a wide variety of tasks and must meet required documentation expectations. 
• Working knowledge of health care industry, caregiving, chronic disease management (a plus)
• Knowledge and appreciation of cultural diversity and low literacy issues in care provision
• Decision making – handles all daily responsibilities relative to coaching a patient.
• Excellent verbal, written and computer literacy necessary
• Ability to work methodically and patiently with limited resources and support
• Ability and willingness to self-motivate, prioritize, and be willing to change processes to improve effectiveness/efficiency. Adapts to changing patient or organizational priorities
• Ability to work independently, while collaborating with other team members
• Ability to work with patients/families of all ages and in a variety of settings