The Transition Coordinator I position is comprised of non-licensed physical and behavioral health experts, who provide an episodic support role to the member’s multidisciplinary care team (MCT). The episodic support roles provided by the Transition Coordinator I may include, but is not limited to, completing warm hand offs, assisting with State required assessments, and coordinating member follow up care.
This position will allow the successful candidate the ability to work remote. This position will require travel within the communities Alliance serves.
Responsbilities & Duties
Assessments and Planning
Assist the Transition Coordinator II with members transitioning from Acute Inpatient care settings or detention facilities to an appropriate lower level of care setting
Obtain necessary releases of information that will improve care management activities on behalf of the member
Provide education and supports to members and legal guardians regarding their rights and responsibilities, available service options, providers availability, and payer requirements
Assist in the completion of Assessments (i.e. Care Needs Screening); assist with interventions identified via the assessments and/or care plans
Actively collaborate with member/guardians and providers to develop discharge plans that adequately address barriers to discharge and applicable Social Determinants of Care
Ensure that assessments and plans are updated, as needed, whenever the members’ life circumstances change
Core Transition Activities
Conduct post-discharge follow up with member to proactively address Physical and Behavioral Health barriers to member adhering to scheduled follow-up appointments
Engage the member’s community primary care physician (PCP) and other providers as appropriate so that they are actively engaged in the transition planning process prior to member’s discharge
Assist the member before discharge (by phone or in person) in selecting a qualified community PCP and clinical specialists as needed
Facilitate arrangements for and scheduling of transportation, in-home services, and follow-up outpatient visits within the appropriate timeframe
Core Documentation Requirements
Complete and upload Warm Hand Offs (WHO) Summaries from members transitioning to Standard Plans and Provider Led Entities (AMH+ and CMA’s)
Process incoming Warm Hand Offs on members transitioning from other Health Plans to Alliance
Assist in scheduling and participate in Virtual Hand off meetings with other Health Plans and Provider Led Entities
Analyze key data to assist with identifying trends are areas of opportunities for improving our communication with Provider Led entities and other Health Plans
Minimum Requirements
Education & Experience
Bachelor’s degree from an accredited college or university in Human Services field and two (2) years of experience working directly with individuals with Behavioral Health and Physical Health conditions.
Or
Bachelor’s degree from an accredited college or university in Non-Human Services field and four (4) years of experience working directly with individuals with Behavioral Health and Physical Health conditions.
Preferred: NACCM, NADD-Specialist, Health Education Specialist, and/or CBIS preferred
Knowledge, Skills, & Abilities
Knowledge of resources and systems in the community that can assist with eliminating SDOH barriers to treatment and whole person living.
A high level of diplomacy and discretion is required
Problem solving, negotiation, arbitration and conflict resolution skills
Must be highly skilled at shifting between macro and micro level planning
Detail oriented
Ability to organize multiple tasks and priorities, and to effectively manage projects from start to finish.
Work activities and quickly adapt to mandated changes and priorities within the department.
The ability to change the focus of his/her activities to meet changing priorities.
Proficiency in Microsoft Office products (such as Word, Excel, Outlook, PowerPoint, etc.) is required.
Salary Range
$25.00 to $32.50/Hourly
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
