Transitions Coordinator - Post Acute-4

CareSource Management Services; Ohio; Híbrido; USD 65.000 - 90.000; Jornada completa

Descripción de la vacante

CareSource Management Services is seeking a Transitions Coordinator- Post Acute. This role oversees member transitions to and from long-term care, respite facilities, and HCBS waivers, partnering with care teams to ensure appropriate supports throughout the transition.

Qualifications include RN degree and 3 years in case management or managed care. BSN preferred; Medicare/Medicaid experience is a plus. Strong organizational and communication skills are essential.

Formación

• Completion of an accredited RN degree program or degree required for Social Worker licensure in Ohio.
• BSN preferred.
• Three years of experience in case management and/or managed care.
• Experience in Medicare/Medicaid managed care environment preferred.
• Post-acute, home care, waiver, or acute clinical care experience preferred.

Responsabilidades

• Acts as point of contact with the Care Coordinator, Waiver Service Coordinator, Medical Director, Provider, or other stakeholders to support coordination of level of care transitions.
• Ensures timely nursing facility-based level of care completion and HCBS waiver enrollment/disenrollment to maintain compliance.
• 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 reviews for NF level of care, respite care, and waiver enrollment/disenrollment.
• Coordinates and provides input in the clinical documentation system for requested services.
• Supports appeals processes as requested and monitors regulatory compliance.
• Coordinates with care coordinators, waiver coordinators, and providers to gather clinical documentation for transitions.
• Facilitates NF discharge planning in a timely and cost-effective manner.
• Reviews documentation in electronic medical records per accreditation and compliance guidelines.

Conocimientos

Microsoft Office

Communication skills

Teamwork

Organizational skills

Assessment

Educación

RN degree

BSN preferred

State licensure eligibility

Descripción del empleo

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