Transition of Care Coordinator

Transition of Care Coordinator

Requirements

• 3-5 years of direct clinical practice experience post master’s degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility
• 2+ years demonstrated proficiency with personal computer, keyboard navigation, and MS Office Suite applications (Teams, Outlook, Word, Excel, SharePoint, etc.)
• Minimum of a Master’s degree in Behavioral/Mental Health or related field
• Unencumbered Behavioral Health clinical license in the state of Oklahoma
• Oklahoma-licensed mental health professional- Licensed Professional Counselor (LPC), Licensed Marriage & Family Therapist (LMFT), Licensed Behavioral Practitioner (LFP), or Licensed Clinical Social Worker (LCSW) with current unencumbered license

Responsibilities

• Ensures safe and appropriate transitions between settings by collaborating with identified points of contact at facilities, members, responsible parties, legal guardians, providers, and support networks through the interdisciplinary care team process.
• Through the use of clinical tools and information/data review, conducts assessments of referred member’s needs/eligibility and determines approach to meeting needs by evaluating available internal and external programs and services.
• Analyzes utilization, self-reported, and clinical data available to consolidate information and begins to identify comprehensive member needs.
• Follows members through their inpatient behavioral health admission and continues oversight through transition from the acute setting to all other settings with the goal of reducing readmissions and increasing permanency in the community.
• Available to conduct face-to-face visits as necessary for high risk members.
• Coordinates care and reassess member’s need 2-day, 7-day, and 14-day post-discharge timeline recommended by the Coleman Care Transitions Model.
• Ensures members transition upon discharge with adequate supervision, recommended behavioral health, physical health, pharmacy resources, and care management support.
• Educates and supports member/caregiver focusing on seven primary areas: medication management, use of personal health record, follow-up care, signs and symptoms of worsening condition, nutrition, functional needs and advance directives.
• Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues.
• Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated.
• Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.
• Applies and/or interprets applicable criteria and clinical guidelines, standardized care management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits.
• Using a holistic approach consults with managers, medical directors and/or other program representatives as needed to overcome barriers to meeting goals and objectives.
• Presents cases at case conferences/rounds to obtain a multidisciplinary view in order to achieve optimal outcomes.
• Engages and builds continued professional relationships at network facilities.
• Identifies and escalates quality of care issues through established channels.
• Communicates and collaborates with medical and behavioral health professionals to influence appropriate member care.
• Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health.
• Provides coaching, information, and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.
• Helps members actively and knowledgably participate with their provider in healthcare decision-making.
• In collaboration with the member and their care team develops and monitors established plans of care to meet the member’s goals.
• Utilizes case management, utilization management, and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedure.

Preferred Qualifications

• Crisis intervention skills preferred
• Managed care/utilization review experience preferred
• Case management and discharge planning experience preferred
• Experience providing care to American Indian/Indigenous American/Native American populations preferred