Job Summary
The Transitions Coordinator- Post Acute is responsible for monitoring and managing the functions related to member level of care transitions to and from long-term care, respite nursing facility services, and the enrollment or disenrollment of home and community based (HCBS) waiver services through clinical review and benefits management. The Coordinator partners with care coordination and waiver service coordination staff in addition to other stakeholders to ensure members receive appropriate supports and services throughout the transition process.
Essential Functions
- Acts as point of contact with the Care Coordinator, Waiver Service Coordinator, Medical Director, Provider, or other stakeholders to function in a collaborative role as a member of the interdisciplinary care team (ICT) to support coordination of level of care transitions related to long-term and respite nursing facility services and HCBS waiver services.
- Ensures timely nursing facility-based level of care completion, respite request reviews, and/or HCBS waiver enrollment/disenrollment to maintain compliance with regulatory and accreditation regulations.
- Verifies eligibility, previous enrollment history, and demographics of members during case reviews.
- Monitors and assists members to maintain benefit eligibility during level of care transitions.
- Completes prospective and retrospective review of requests for NF level of care determinations, respite care, and waiver enrollment or disenrollment per established processes.
- Coordinates, oversees, and provides input in the clinical documentation system for requested services per established processes.
- Responsible for clinical functions related to level of care transition processes; supports appeals processes as requested.
- Coordinates with the Care Coordinator, Waiver Service Coordinator, provider, and/or other stakeholders to gather clinical documentation to complete level of care transition processes.
- Coordinates care with care coordinators, waiver service coordinators, providers, and/or other stakeholders to facilitate NF discharge planning in a timely and cost-effective manner.
- Reviews current documentation of contacts, treatment plans, case notes, referrals, and assessments in the electronic medical record according to current accreditation and compliance guidelines.
- Assists with development and implementation of care plans as needed, by defining specific issues, prioritized goals and interventions as agreed to by all parties.
- Documents, identifies and communicates with Health Partners, Care Coordinators, Waiver Service Coordinators, Medical Directors, Discharge Planners, Providers and/or other stakeholders as needed for care coordination and to establish safe transition plans between levels of care when clinically appropriate.
- Closely collaborates with care coordinators and waiver service coordinators for any identified changes in eligibility for a member's assessed level of care and/or with any changes in level of care determinations identified by providers or other external stakeholders.
- Maintains knowledge of federal and state regulations governing CareSource, State Contracts and Provider Agreements, and CareSource Medicare and Medicaid benefits (including HCBS and nursing facility-based services).
- Attends and participates in interdisciplinary team meetings, State Hearings, and/or Medical Advisement meetings, when requested.
- Escalates identified care coordination needs to the appropriate care coordination and/or waiver service coordination team member(s) and leader(s).
- Identifies and refer quality issues to Quality Improvement.
- Maintains appropriate documentation following protocols and guidelines of the MyCare Program.
- Precepts and/or mentors new staff.
- Participates in special projects or research, as requested.
- Maintains required reporting and assists with data analysis, as requested.
- Performs any other job related duties as requested.
Education and Experience
- Completion of an accredited Registered Nurse (RN) degree program or degree required to obtain Social Worker licensure in the State of Ohio is required
- Bachelor of Science (B.S) in Nursing (BSN) or equivalent baccalaureate degree in healthcare field preferred
- Three (3) years of experience in case management and/or managed care required
- Experience in Medicare and/or Medicaid managed care environment is preferred
- Post-acute, home care, waiver, or acute clinical care experience is preferred
Competencies, Knowledge and Skills
- Intermediate proficiency in Microsoft Office Suite
- Basic level knowledge of a Windows based environment
- Ability to operate smart phone, iPad, or other mobile communication devices to ensure productivity and ability to perform essential functions
- Excellent written and verbal communication skills
- Demonstrated ability to work with diverse populations in a non-judgmental manner
- Ability to work independently and within a team
- Strong organizational skills
- Excellent assessment skills
- Attention to detail
- Knowledge of Medicare and Medicaid
- Critical thinking and listening skills
- Time management skills
- Customer service oriented
- Decision making/problem solving skills
- Knowledge of evidence-based medical criteria and/or standards of care
Licensure and Certification
- Current, unrestricted Registered Nurse (RN), Licensed Social Worker (LSW), or Licensed Independent Social Worker (LISW) licensure in state of Ohio is required
- Multi-state licensure is preferred
- Case Management Certification (CCM) is preferred
Working Conditions
- General office environment; may be required to sit or stand for extended periods of time
- Attendance at in-person meeting may be required
- Travel is not typically required
Compensation Range
$62,700.00 - $100,400.00
Compensation Type (hourly/salary)
Salary