Care Transition Coordinator
Summary: The Care Transition Coordinator (CTC) is responsible for the planning and implementation of care transition services for consumers recently identified for release from a hospital or post-acute setting. These duties include primary responsibility in the area(s) of consumer assessment and program eligibility, planning for and delivering services within local networks and resources, and coordinating care/services with multi-disciplinary health care providers and non-clinical care service providers. This is a 12-month grant-funded position.
- The CTC Coordinator performs the following duties through the Hospital2Home pilot demonstration. The CTC Coordinator serves as the primary point of contact to determine program eligibility, consumer care needs, and services planning. Related duties include but may not be limited to:
- Educate and orient Hospital2Home participants and family/support persons of the services and program protocols.
- Use care management data and assessment methods to determine appropriateness of pilot participation for consumer.
- Participate in consumer’s discharge planning. Working with consumer, develop care plan including incorporating personal goals and care needs for personal management, employment success, travel orientation, home management and safety, self-care, utilization of support persons and/or adaptive equipment.
- In conjunction with the multi-disciplinary health care team, plan and facilitate necessary post-discharge support including engaging para-professional staff as necessary in order to ensure plans and goals are achieved and consumer outcomes are maximized. Monitor and evaluate care plan, service quality, and program eligibility; make adjustments as necessary.
- Act as primary liaison between and among consumer and multi-disciplinary team, support services providers both within and outside of LEAP. Make regular home visits as necessary to deliver and monitor services.
- Provide support in the acquisition of independent living skills (improved functioning) needed to achieve level of independence chosen by each consumer and authorized by referral source including, but not limited to: personal management, interpersonal and social skills, community access, resource management, employment services and/or success, travel orientation, home management and safety, self-care, utilization of support persons and/or adaptive equipment as requested.
- Exercise a high level of prompt decision-making aptitude, balancing the needs of both the individual consumer and family. Utilize resources and tools to identify necessary services and develop a comprehensive care plan.
- Demonstrate understanding of program’s financial support structure, as well as staff’s role in leveraging financial resources. Work collaboratively with Program Director to meet program management needs, including program evaluation, grant maintenance and reporting, and stakeholder relationships.
- Develop and maintain appropriate documentation, records and reports to include individual plans and service record. Document progress and prepare reports, compile and maintain consumer case records and documentation (case files and consumer database) in accordance with policies, procedures and practices set forth by LEAP, referral and funding requirements (i.e. State and Federal regulations), accrediting and funding standards (i.e. Dept. of Education, CARF) and all other applicable regulations.
- Comply with all policies and procedures set forth by LEAP as well as all agency, funder, and legal guidelines regarding consumer privacy and confidentiality, including the need for written authorization from the consumer and/or legal guardian prior to any release of confidential information. Protects consumer privacy and confidentiality at all times.
- Communicate progress, issues and goals with team leaders, other team members, program and executive directors, applicable staff members and others as required.
- Articulate LEAP’s overall mission and this position’s role in that mission through enhancing, protecting, and removing barriers to the full exercise of civil rights of persons with disabilities. Participate in LEAP advocacy efforts and events as requested.
- Maintain professional attire, speech and manners.
- Perform related duties as assigned.
REQUIREMENTS / QUALIFICATIONS:
- Minimum 3 years’ experience in a case and or care manager role, specifically for the adult-with-disability, frail adult or cognitively impaired seniors population is preferred. Demonstrated success in community-based and fee-for-services home health care and social services.
- Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment.
- Problem solving, negotiation and conflict resolution skills are essential to balance the needs of both internal and external customers. High level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance.
- Must have knowledge of government/community agencies and resources, such as Medicare/Medicaid payment structures, long term care or other applicable resources/services. Demonstrated understanding of healthcare innovation or expansion to address Social Determinants of Health. Familiarity with all SSA benefits, appeals process and work incentives, state and community programs/benefits and their interactions with, and impact upon, other benefits.
- Knowledge of all LEAP services, Americans with Disabilities Act (ADA), the Rehabilitation Act of 1973, accommodations and work/home modifications, assistive and adaptive technology and related resources, and the issues and needs of persons with disabilities.
- Working knowledge of CARF standards.
- Ability to represent LEAP to consumers and the community.
- Ability to work well in a team, exhibiting good interpersonal skills and positive attitude.
- Ability to communicate clearly and concisely in both verbal and written forms.
- Understand, support and adhere to the Independent Living philosophy.
- Demonstration of time management and problem-solving skills, along with ability to establish and maintain appropriate boundaries and manage multiple priorities.
- Ability to work well with people of all backgrounds, incomes, ages, races and disabilities (i.e. mental health, physical, cognitive, sensory).
- Bachelor’s degree in social services or related field such as counseling, nursing, occupational therapy). Licensure or certification in care management (e.g., NASW, CMC) is preferred.
- Minimum three years’ experience in hospital or health care setting, and/or in social work, counseling or related field, providing similar services to population served. 5-7 years of overall human services experience preferred.
- Experience with project management aimed at addressing root causes of poor health, maximizing health communications, and developing other community-based innovations to improve the health of communities is strongly preferred.
- Experience in transportation, housing, health services, recreational and wellness activities is also strongly preferred.
- Experience working with a variety of people with disabilities, and familiarity with disability-related advocacy, vocational and community support programs.
- Current certification in first aid and CPR (required within two months of employment) and MUI training.
- Proficiency with Microsoft Office Suite (MS Outlook, Word, Excel, PowerPoint) with ability to use spreadsheets and databases in order to develop high quality work products.
- Must have reliable transportation to provide community services and home-based services.
- If driving a vehicle to provide community services and home-based services, must have a valid Ohio driver’s license, a clear driving record and proof of personal vehicle insurance coverage (required to be maintained at all times for this position).
This is a mobile-based position and driving is an essential function of the position. Most work responsibilities are performed during normal business hours; however, some work outside of normal business hours may be required. Employee must be able to alter daily operations to fit the demands of the position. Work is performed with considerable independence, with most work performed in the community and away from the office.
Persons with disabilities are encouraged to apply.
Complete job description will be available during the interview process
Interested applicants, please apply on Indeed or submit your resume and cover below.
Deadline: Open until filled