CCT Transition Coordinator

Libertana is a healthcare organization seeking a Transition Coordinator to assist SNF residents in their transition to community living. The role involves coordinating with various stakeholders to ensure a smooth transition and managing care plans for residents.

Responsibilities

• Assists clients with housing and transition coordination
• Follows up with SNF case managers, discharge planners and/or representatives, establishing working relationships and educating them about the CCT program and the variables available to their patients/clients on discharge
• Identifies and interviews residents for pre-screening and isolates client needs
• Performs phone calls to clients/SNF’s at least 1 month prior to discharge from “Waitlist” to gather documentation and start identifying possible RCFE Placements
• Coordinates agency RN visits to assess resident and to help prepare Initial Care Plan (ICP)
• Completes the Initial Care Plan (ICP) and submits to DHCS for review
• Prepares and submits 20-hour TAR with appropriate attachments. Prepares and submits the 100 TAR
• Works on housing and other needs of the resident. Coordinates DME and assistive devices with SNF and DME Company
• Maintains contact with SNF’s and residents while working on the resident’s care plan and other needs
• Applies for appropriate waiver based on the resident’s needs (ALW/NF/IHSS)
• Works on Final Care Plan (FCP), obtains physician signature, and attaches to PTC TAR
• Obtains transition plan signatures on date of transition and attaches to PTC TAR
• Helps resident transition back into the community as outlined in ICP
• Assures continuance of PTC to provide case management to be followed for the first year at home
• Presents all time keeping to billing department weekly
• Knowledge of confidentiality, HIPAA and healthcare laws and regulations
• Maintains proper timekeeping
• Maintains all required credentials up to date
• Reports fraud and abuse
• Knowledge of mandated reporting
• Conducts timely recording and/or documentation of all client contact
• Attends all state mandated in-service trainings
• Driving may be required to geographical areas that are covered by the company
• Performs other duties as assigned

Skills

• Is at least 18 years of age
• Must have adequate physical and mental health
• Ability to read, write and follow instructions in English
• Maintains good organizational skills
• Self-directed and able to work with minimal supervision
• Possesses excellent analytical skills
• Ability to establish and maintain good communication and relationships with all office, field and administrative personnel
• Effective written and verbal communications skills
• Knowledge of confidentiality, HIPAA and healthcare laws and regulations
• Maintains proper timekeeping
• Maintains all required credentials up to date
• Reports fraud and abuse
• Knowledge of mandated reporting
• Conducts timely recording and/or documentation of all client contact
• Attends all state mandated in-service trainings
• Driving may be required to geographical areas that are covered by the company
• Bachelor's degree in healthcare, business administration or related field preferred
• Previous Health Care experience preferred
• Background and/or knowledge of developing reports, newsletters, brochures, statistics, and information analysis desired
• Experience in Community Liaison in the Los Angeles community

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