Job DescriptionWe are filling three new Transition Coordinator positions for coverage in the Tidewater, Central and Northern regions in Virginia. Candidates must live within one of those regions, which are outlined below.
Central Region: The area from Stafford County to Prince Edward County to Southhampton County to Lancaster County.
Northern Region: The area from Page County to Frederick County to Fairfax County to Culpeper County.
Tidewater Region: The area from Suffolk County to Gloucester County to Virginia Beach County.
The Transition Coordinator assists individuals with transitions where the goal is to serve individuals in the community versus relying on institutional care including transitioning individuals from nursing facilities, hospitals, inpatient rehabilitation, or other institutional care settings into the community, but would also include helping individuals remain in the community. This role does not maintain a caseload.
- Leads care transition planning process to include face-to-face or telephonic contact in the hospital prior upon admission to complete a discharge plan; in-home visits or phone call within 1-2 days post discharge to determine if the member is following the discharge plan, medication plan, and ensures follow up appointments have been made.
- Participates in discharge planning for Members transitioning from acute institutional settings to lower levels of care, including Long Stay Hospitals, Nursing Facilities, and the community. Single, non-recurrent (within 30 days) medical stays of two nights or less do not require the participation of the Transition Care Coordinator unless indicated by the Member`s needs and circumstances.
- Coordinates with the assigned care coordinator in discharge planning activities to ensure a safe transition that meets the Member`s needs and preferences.
- Coordinates with Utilization Management staff, as indicated regarding discharge planning.
- Coordinates with Nursing Facility staff, the Member`s assigned care coordinator, and the Member when it is identified that the Member wishes to transition from Nursing Facility care to the community.
- Provides support to care coordinators to maintain Members in the community in lieu of transitioning to institutional settings, as needed.
- Serves as the customer`s point of contact when discussing complex, challenging cases that need assistance with transition activities. Other staff with relevant expertise and experience may be assigned to support the dedicated staff individual;
- For Dual eligible members enrolled in a Dual Eligible Special Need Plan (DSNP), the Regional Transition Coordinator shall also work with the DSNP care coordinator upon approval of the Member, to coordinate the above activities.
- Proactively identifies Managed Long Term Services and Support (MLTSS) members in nursing facilities or other institutions who are candidates for transitioning to the community and for assisting with the completion of the transition process.
- Other duties as assigned.
General Job Information
Job FamilyClinical Services Group
CountryUnited States of America
FLSA StatusUnited States of America (Exempt)
Recruiting Start Date1/30/2019
Date Requisition Created1/26/2019
EducationAssociates: Nursing (Required), Bachelors: Healthcare (Required)
License and Certifications - RequiredRN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt
License and Certifications - Preferred
Other Job Requirements
- One or more years of experience working directly with individuals who meet the MLTSS target population criteria OR one or more years of experience working as a RN.
- May consider a Bachelors degree in a health or human services field with at least two years of experience working with individuals who are elderly and/or have disabilities in lieu of RN but RN will be given preference.
- Demonstrated ability to communicate with members who have complex medical needs and may have communication barriers.
- Comfortable with conducting home visits and commuting within the service area.
- Understands and adapts appropriately to issues related to communication, cognitive or other barriers.
- Strong organizational skills and the ability to prioritize and follow through on multiple projects in a timely manner.
- Home Care, Long-Term Care, MLTC experience preferred, including appropriate support services in the community.
- Bi or multilingual ability preferred.
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled
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