Regional Transitional Care Manager - Western, VA Markets

Primary Responsibilities

• Participate in discharge planning for Members transitioning from LTC facility settings to the community
• Collaborate and Coordinate with Nursing Facility staff, the Member's assigned care coordinator, and the Member when it is identified that the Member wishes to transition from NF care to the community
• Support care coordinators to maintain Members in the community in lieu of transitioning to institutional settings, as needed
• Collaborate and partner with community resources (e.g. CILs, CSBs, AAAs, etc.) and work with staff to facilitate safe transitions for members willing and able to transition from custodial NF care back to a community setting of their choice
• Provide consistent follow up during the first year after discharge and make adjustments to the transition plan to assure acclimation and integration into the community as needed by the Member
• For Dual eligible members enrolled in a DSNP, coordinate the above activities with the DSNP care coordinator upon approval of the Member
• Review daily census, prioritize daily work and monitor progress of transitions in accordance with Care Coordination policies
• Actively collaborate and communicate with physicians and providers to arrange appropriate follow up, discharge planning and/or alternative care and services for plan members
• Coordinate the authorization process for discharge planning needs in accordance with Plan policy and procedure
• Participate in NF ICT/ Care Team meetings as appropriate; NF Rounds, Quarterly team meetings with NF CC and other meetings as required to facilitate transitions
• Coordinate transition of members to other Level Care Coordinators as indicated
• Perform other delegated duties as assigned

Required Qualifications

• Social Worker with BSW degree or LPN with current/unrestricted license in Virginia
• 3+ years of care coordination or behavioral health experience and/or work in a healthcare environment
• 1+ years of experience directly working with individuals with complex medical or behavioral needs
• Proficient computer skills in Microsoft Office to include Word, Outlook and the ability to type and talk at the same time and toggle between multiple screens
• Demonstrate the ability to communicate with members who have complex medical needs, the elderly, individuals with physical disabilities, and/or those who may have communication barriers
• Demonstrate ability to communicate and collaborate with multiple stakeholders on the implementation the transition plan
• Driver's License and access to reliable transportation

Preferred Qualifications

• LSW/LCSW
• Certified Case Manager
• Experience managing transitions between care setting, including transition from nursing facility care to care in the community
• Experience providing care coordination to persons receiving long-term care and/or home and community based services
• Experience working with Medicaid/Medicare population
• Long term care/geriatric experience
• Case management experience in a clinical setting (hospital, long term care, home health, hospice) or managed care