Continuity of Care Nav

I) Job Purpose

This position is responsible for the coordination of Care for clients transitioning into and out of hospitals, jails, and state institutions.  The Continuity of Care Navigator (COC) is the liaison for the Center and acts as the point of contact for intermediate care facilities (ICF), Permanency Planning, John Peter Smith hospital, Cook Children's hospital, North Texas State Hospital, Tarrant County jail, and the State Supported Living Centers (SSLCs).  

II) Essential Functions

A) Provides transition planning to individuals transitioning into or out of SSLCs, hospitals, jails, and NTSH. 

B) Is the main point of contact for the SSLC's, hospitals, jails, and NTSH.

C) Assures that any individual entering or leaving any of these facilities has admissions and discharge planning-by way of incorporating the teams for the person served and the person.   

D) Completes NTSH applications for minors in Tarrant County who have been identified as having an intellectual or developmental disability.

E) Monitors individuals in the state hospitals and participates in treatment team meetings, as needed. COC will request hospitalization extensions, if appropriate. 

F) For individuals not currently in services, the COC will facilitate the appropriate screening and will ensure the individual receives a priority Intake appointment.

G) Expected to coordinate, arrange, and provide for appropriate services and supports during and post-move for any of the individuals identified for transition out of a SSLC or state hospital.

H) Evaluates the need for intensive services and supports for each of the individuals served in the above institutions.  Must call upon professionals for assessments as deemed by the IDT team.   

I) Completion of permanency planning for individuals residing in state facilities: SSLCs, ICFs, and state hospitals.

J) COC will complete the permanency plan report and mail copies to involved parties as outlined in TAC and performance contract.

K) Completes IDT reports and applications for individuals requesting SSLC admission. COC is responsible for filing appropriate paperwork with the courts and testifies in court to obtain the civil commitment.

L) Enrolls individuals in the HCS program and participates in the discovery process to build the individuals person directed plan. Participates in the Community Living Discharge Planning (CLDP) and presents the individual to the Cross Systems Consultation Team (CSCT) to obtain professional recommendations, prior to enrollment.

M) Ensures that the program provider has all of the records that are needed to provide care for the person, i.e. NTSH records, SSLC records, medical records, etc.

N) Upon admission, COC conducts ICF enrollment procedures, including ID/RC submission and permanency planning, if applicable.

O) Coordinates the completion of new diagnostic testing as required by TAC. 

P) Writes the IDT report and submits the report to HHSC for review, if the individual is a minor the COC is responsible for sending the completed report to CRCG for approval prior to submitting to HHSC.

Q) Coordinates quarterly ICF provider fairs.

R) Attend Cross Systems Consultation Team (CSCT) to provide review and support to Service Coordination of diversion, transition, SSLC application, and additional resources and referrals as management are absent.

S) Train new staff on policies, procedures, and resources available to prepare Service Coordinators to complete Intakes in the community.

T) Equip community members, including schools, mental health agencies, families, and individuals, with knowledge regarding intake procedures and services available within MHMR.

U) Performance standards are performed as applicable with MHMR's We CARE values "We Connect People in Our Community. We Provide Access to Services. We Link People to Resources. We Empower People."

V) Performs other job duties or responsibilities as requested or assigned.

III) Knowledge of Laws, Regulations, Policies/Procedures, Skills, and Abilities

A) ICF-MR rules 

B) TxHmL Standards

C) HCS Rules and Guidelines

D) Service Coordination Rule

E) Medicaid Billing guidelines

F) DFPS Rules regarding abuse and neglect

G) MHMRTC Policies and Procedures

H) Performance Contract 

I) Laws related to persons with Intellectual disabilities or Related Conditions.

J) Rules pertaining to Medicaid and Medicaid eligibility

K) Waiver requirements

L) Texas Health and Safety Code

M) Code of Criminal Procedure

N) Service Definition Manual

O) Texas Administrative Code (TAC) 

P) Family Code

IV) Internal & External Customer Service

A) This position requires internal and external contacts.  This person is expected to uphold the agencies values when working with both internal and external contacts, which includes helping access services with a caring attitude.  

V) Travel

A) Adhere to MHMR Mileage and Travel reimbursement policy and any other aspect regarding travel.

VI) Equipment Used

A) Utilized as required for position.  

Lifting Requirements 0-15#

VII) Minimum Qualifications

A) Minimum Education: Bachelor's Degree

B) Defined Education: Health or Human Services

C) Preferences: None

D) Substitutions: High School Diploma/GED and 2 years' paid experience as a Case Manager in state Parent Case Manager Program or graduated from Partners in Policy Making and personal experience as immediate family member of an individual with an Intellectual and/or Developmental Disability

E) Years' Experience: Six (6) years

F) Defined Experience: Health or Human Services

G) License/Certifications: Valid Texas driver's license with acceptable driving record

H) Special Courses: None

I) Supervisory Experience: None

VIII) Agency Requirements

A) All staff are required to participate in agency Emergency Preparedness and Environmental Safety programs and may be assigned by their department as a key/essential staff level function during critical events or for the purpose of sustaining business continuity.

B) This position may require temporary or permanent re-assignment to any MHMR Tarrant facility as determined by program needs and/or the Division/Director.

C) Assigned work hours may change as the needs of the agency change.

D) The Functional Title of this position may change as the needs of the agency change.

E) All work will be completed within the scheduled work hours. All non-exempt (hourly) employees are expected to clock in and clock out for each work shift, no work should be done off the clock.

F) MHMR reserves the right to change, add to or eliminate positions as it deems appropriate. 

G) Employment is at will, as well as agency needs may change.

H) Agency dress code is to be followed at all times.

I) Physical on-site presence, including regular attendance and punctuality, is an essential function of this position. Any changes or adjustments to your assigned work schedule or shift hours must be approved by your supervisor in advance.

All staff are required to participate in agency Emergency Preparedness and Environmental Safety programs and may be assigned by their departments as a key/essential staff level function during critical events or for the purpose of sustaining business continuity.

This position may require temporary or permanent re-assignment to any MHMR Tarrant facility as determined by program needs and /or the Division/Director.

Assigned work hours may change as the needs of the agency change.

The functional Title of this position may change as the needs of the agency change.

All work will be complete within the scheduled work hours.  All non-exempt (hourly) employee are expected to clock In and out for each work shift, no work done should be done off the clock.

Prior approval from supervisor is required for all Paid Time Off (PTO) and Overtime.

MHMR reserves the tight to change, and to or eliminate a position as it deems appropriate.

Employment is at will, as well as agency needs may change.

Agency dress code is to be followed at all times.

Physical on-site presence, including regular attendance and punctuality is an essential function of this position.  Any change or adjustments to your assigned work schedule or shift hours must be approved by your supervisor in advance.

Our Benefits:

Our total rewards program offers benefits* to full time employees beginning 1st of the month following hire date including but not limited to:

Comprehensive healthcare options (Medical, Dental, and Vision)

Life insurance and additional supplemental accident and hospitalization plans

401a match and 457 deferred compensation plans

Paid vacation and holidays; varied flexible work environment locations

Annual tuition reimbursement program

Student Loan Forgiveness

Professional development programs and training

And more.....

Insurance eligibility:

Full time employees begin 1st of the month following hire date

Market driven positions (full time or part time) begin immediately after hire date

Select part time market driven positions are eligible for most insurance plans

Substitute status jobs are not eligible for benefits

For more information, click https://www.mhmrtarrant.org/benefits/ 

Additional Information

*MHMR of Tarrant County ("MHMR") and its affiliates and subsidiaries have an internal recruiting department. MHMR may supplement that internal capability from time to time with assistance from temporary staffing agencies, placement services, and professional recruiters herein after referred to collectively as "Recruiters"). Recruiters are hereby specifically directed NOT to contact MHMR employees directly in an attempt to present candidates - MHMR recruiting team or other authorized MHMR personnel must present ALL candidates to hiring managers. For more information please visit our website www.mhmrtc.org