Transition Care Coordinator- VAAA Cares
Transition Care Coordinator- VAAA Cares
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$ 50000 - 60000
1 Vacancy
Job Description
Job Details
Description
Location: Hampton/Newport News Virginia Virginia Resident- In-Field Home-Based & Telephonic
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 bachelors 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 Virginias Medicaid LTSS program population and/or the Cardinal Care Contract for care management.Salary: $50000/yr-$60000/yr. Location: Hampton/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 Members 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 Members 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
Qualifications
- Transitional Care Coordinator must be located in Virginia while performing job responsibilities.
- Bachelors 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 Virginias Medicaid LTSS program population and/or the Cardinal Care Contract for care management.
- Home-based telephonic position with field work. Home-based internet service preferred. Must have reliable transportation and a valid drivers license and be able to attend in-person training when required as well as in-home home patient visits.
- Corporate office located in Urbanna Virginia. On-site work may also be required for training etc.
- Ability to use a computer with internet-based software and Microsoft Office/Excel.
- Must possess a valid drivers license vehicle insurance and reliable vehicle
- This position is a remote work from home and in-field position with some physical requirements (ability to lift 20 lbs. walking and climbing stairs). They will need to be able to read write and communicate. Ability to drive to client homes for in-home patient care.
FLSA status: This is a full-time exempt position.
Disclaimer: This job description is not designed to cover or contain a comprehensive listing of all activities duties or responsibilities that are required of the employee. From time to time the supervisor will ask the job holder to perform additional duties related to the completion of the work. Other duties may be assigned from other programs as needed.
Bay Aging is an Equal Opportunity Employer. All applicants will be considered for employment without discrimination on the basis of race color religion sex national origin age veteran or disability status. Bay Aging is committed to providing access equal opportunity and reasonable accommodation for individuals with disabilities in employment its services programs and activities. To request reasonable accommodation contact MaDena DuChemin Director Human Resources at Ext. 1228 or .
Required Experience:
IC
Employment Type
Full-Time
