Transition Coordinator II - Emergency Department (Full Time, Cumberland County, North Carolina Based

The Transition Coordinator II provides Transitional Care Management and Physical Health Consultation for members with physical and/or behavioral health needs in Acute Care facilities, State Operated Developmental Centers, and Justice System settings. For Transition Coordinator II’s assigned to a facility, there will be active and onsite participation in discharge planning beginning with admission.

This is a full-time hybrid opportunity. There is no expectation of coming into the office routinely, however, the selected candidate must be available to report onsite to the Alliance Office for business meetings as needed. The successful candidate will also be required to travel throughout Cumberland County area as needed and will need to reside within 45 minutes of Cumberland County, North Carolina. 

Responsibilities & Duties

Provide Care Team Support

Support members transitioning from inpatient settings to the appropriate lower or lateral level of care

Provide subject matter expertise, within scope, regarding member’s physical and/or behavioral health to support the development and delivery of a whole person approach to Care Management

Work collaboratively with other Alliance staff, behavioral health providers, primary care physicians, specialty care providers and other community partners and stakeholders to support members in their home communities

 Core Transitional Care Management Function

Conducts on site visit the member during their stay in an

institution (e.g., acute, subacute and long–term stay facilities)

Conduct outreach to the member’s providers

Obtain a copy of the discharge plan and review the discharge plan with the member and facility staff

Facilitate clinical handoffs

Refer and assist members in accessing needed social services and supports identified as part of the transitional care management process, including access to housing

Assist the member in obtaining needed medications prior to discharge, ensure an appropriate care team member conducts medication reconciliation/management and support medication adherence

Develop a ninety (90) day post-discharge transition plan prior to discharge from residential or inpatient settings, in consultation with the member, facility staff and the member’s care team, that outlines how the member will maintain or access needed services and supports, transition to the new care setting, and integrate into their community

Communicate and provide education to the member and the member’s caregivers and providers to promote understanding of the ninety (90) day post-discharge transition plan

(Assist with scheduling of transportation, in-home services, and follow-up outpatient visits with appropriate providers within a maximum of seven (7) Calendar Days post-discharge, unless required within a shorter timeframe

Ensures follows up with the member within forty-eight (48) hours of discharge

Conduct In reach and transitions for Special Populations receiving care in Inpatient settings (State Hospitals, PRTF’s) 

Monitoring/Coordination

Appropriately escalate high risk/high visibility and/or complex barriers/needs members who may have difficulty transitioning out of the facility in a timely manner to supervisors. High risk can involve Health and Safety of a member, staff, or organizational risk

Review cases with clinical complexity with direct supervisor and follow escalation protocols to ensure timely engagement from members or our Medical Team and Provider Networks

Obtain information releases that will improve care management activities on behalf of the member

Reports care quality concerns to Quality Management as needed

Documentation

Ensure all clinical documentation (e.g. goals, plans, progress notes, etc.) meet state, agency, and Medicaid requirements

Ensure accuracy and quality of Warm Hand Off summaries

Follow administrative procedures and effectively manages caseload

Data

Review, validate and interpret risk stratification data and population health groups and recommend changes or adjustments to care management approach as needed

Utilize data to analyze needs of the members we serve, guide staff training development, identify resource needs and consistency of workflow implementation across disciplines

Travel

Travel between Alliance offices, attending meetings on behalf of Alliance, participating in Alliance sponsored events, etc may be required

Travel to meet with members, providers, stakeholders, attend court hearings etc. is required

Minimum Requirements

Education & Experience

Graduation from an accredited school of Nursing and three (3) years of full-time, post degree experience providing care management, case management, care coordination, discharge planning, or utilization management to members with Behavioral Health and Physical Health conditions in a behavioral health, medical, or managed care setting. Must have a valid, active RN license in North Carolina. 

Or

Master’s degree from an accredited college or university in Human Services or related field and at least two (2) years of full-time, post graduate degree experience providing care management, case management, care coordination, discharge planning, or utilization management to members with Behavioral Health and Physical Health conditions in a behavioral health, medical, or managed care setting.

Must have a valid, active clinical license (LCSW, LMFT, LCAS, LCMHC, LPA) in North Carolina. 

Preferred:

NACCM, NADD-Specialist, Health Education Specialist, and/or CBIS certification preferred.

Knowledge, Skills, & Abilities

A demonstrated Knowledge of the assessment and treatment of mental health, substance abuse, intellectual and developmental disabilities, 

Knowledge of legal, waiver, accreditation standards and program practices/requirements. 

Knowledge of the Alliance Health service benefit plans and network providers. 

Person Centered Thinking/planning

The employee must be detail oriented, 

Ability to independently organize multiple tasks, priorities, and to effectively manage an assigned caseload under pressure of deadlines.

Exceptional interpersonal skills, highly effective communication ability, 

Ability to make prompt independent decisions based upon relevant facts and established processes.

Problem solving, negotiation and conflict resolution skills 

Proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) is required.

 Employment for this position is contingent upon a satisfactory background and MVR (Motor Vehicle Registration) check, which will be performed after acceptance of an offer of employment and prior to the employee's start date.