Works in collaboration with a member's primary care manager to ensure safe and appropriate transitions between levels of care, including working as a part of the interdisciplinary care team in the development and execution of a person-centered transition plan. Coordinates all support staff needed, (e.g., Housing Coordinators, DME Specialists, etc.) and services required are in place for a safe transition. Collaborates with family/caregivers to identify and ensure caregiver needs are met. Establishes and maintains best practices that reflect regional variations in service delivery, including establishing relationships with key facilities, providers, and home and community based (HCBS) resources to assist in transitions. Proactively identifies members residing in nursing facilities or other institutions who are candidates for transitioning back to the community. Assists in reviewing and analyzing data related to rebalancing and developing action plans to meet rebalancing goals.
DEPARTMENT: Legal-Regulatory Affairs
REPORTS TO: Director, Product Operations
Location: Tampa, New Port Richey, Osceola or Orange County, FL
- Conducts research, including reviewing reports, medical records, service authorizations, claims history, case notes, caregiver needs etc., to determine member needs for safe transitions to the community.
- When indicated, conducts telephonic outreach to members, providers and community organizations to support Case Management and/or Quality Improvement, regulatory and contractual metrics and requirements related to community transitions.
- Maintains accurate records of activities in the care management platform.
- Maintains HIPAA standards and ensures confidentiality of protected health information. Reports critical incidents and information regarding quality of care issues.
- Serves as a liaison in corresponding and communicating with providers, vendors and other identified stakeholders to influence rebalancing metrics.
- Positively collaborates with field health services staff as a part of the interdisciplinary care team to lead transition activities in conjunction with the primary care manager.
- Ensures compliance with all state and federal regulations and guidelines.
- Acts as subject matter expert in regards to regional best practices that support successful community transitions.
- Identifies strategic community providers and stakeholders and establishes positive partnerships and innovative approaches to create/expand community capacity to positively influence rebalancing.
- Analyzes data to proactively identify areas of opportunity for rebalancing and develops action plans to meet goals.
- Represents the department / leadership in assigned meetings, special projects, and/or community-facing events.
- Performs other duties as assigned.