Works in collaboration with a member's primary care manager (CM) 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, (e.g., Housing Outreach Specialist, DME Specialist, Community Advocate) and services required for a safe transition. Along with the primary CM, collaborates with family/caregivers to identify and ensure caregiver needs are met and services are in place to support a successful return to the community. Establishes and maintains best practices reflecting regional variations affecting successful transitions and HCBS capacity, including establishing relationships with key facilities, providers, and home and community based (HCBS) resources to assist in transitions. Assists with identifying resources with specialized capabilities when members with complex needs transition to the community. 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. Partners with internal staff and external stakeholders to develop innovate solutions to expanding HCBS capacity based on Regional nuances and State/Federal regulations.
Reports to: Director Field Care Management
Location: Tampa, FLEssential Functions:
- Responsible for identifying Long-Term Care members with an opportunity to re-enter the community and exercises independent judgement in the final determination of the appropriateness of the member to transition out of the facility.
- Conducts research, including reviewing reports, medical records, service authorizations, claims history, case notes, caregiver needs etc., and employs clinical expertise to determine member needs for safe transitions to the community and supports the member’s residential choice in the least restrictive setting.
- Collaborates with the primary Care Manager to conduct 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.
- 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.
- Maintains accurate records of activities in the care management platform.
- Maintains HIPAA standards and ensures confidentiality of protected health information. Reports critical incidents, including incidents of abuse, neglect, and exploitation, 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.
- Ensures compliance with all state and federal regulations and guidelines.
- Acts as subject matter expert in regards to regional best practices, contract requirements, and department processes 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.
- Determines relevant data points to analyze, and performs analysis to proactively identify areas of opportunity for rebalancing and develops action plans to meet goals.
- Represents supervisor and/or management team in assigned meetings, special projects, and/or community-facing events.
- Acts as lead to complete specific contract required functions to ensure compliance, communicating with specific state partners and providers.
- Performs other duties as assigned.