Transition Coordinator II (Full Time, Hybrid in Johnston and/or Orange County areas, North Carolina Based)

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 is a full-time hybrid opportunity. There is no expectation of coming into the office routinely, however, the selected candidate must be available to report onsite to the Alliance Office for business meetings as needed. The successful candidate may also be required to travel weekly throughout Johnston County and/or Orange County area as needed. 

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

Travel

• Travel between Alliance offices, attending meetings on behalf of Alliance, participating in Alliance sponsored events, etc may be required
• Travel to meet with members, providers, stakeholders, attend court hearings etc. is required

Minimum Requirements

Education & Experience

Graduation from an accredited school of Nursing and three (3) years of full