Lwce Transition Care Coordinator

JOB TITLE: COMMUNITY TRANSITION CARE COORDINATOR

SUPERVISOR: LWCE CHIEF OPERATIONS OFFICER

KNOWLEDGE REQUIRED:

1. BS Degree.

2. Excellent verbal communication skills.

3. Excellent interpersonal and customer service skills.

4. Proficient with Microsoft Office Suite or related software.

5. Proficient with Workshop Wizard.

6. Proficient in public speaking and development of presentation.

7. Ability to use multiple platforms for trainings and presentations

PHYSICAL REQUIREMENTS:

1. Intermittent periods of sitting at a desk and working on a computer.

OTHER REQUIREMENTS:

1. Criminal background check required prior to employment.

2. Reliable transportation.

3. Reliable internet capability for remote working.

4. Flexible schedule.

DUTIES:

The Community Transition Care (CTC) Coordinator works with Tidal Health and Atlantic General Hospitals, Care Transformation Organizations, and physician practices to connect patients to resources with Health-Related Social Needs. The CTC Coordinator will support the Community Transition Care staff and program at MAC, Worcester MAP, and any other contracted organization across the state, linking clinical referrals to non-clinical resources.

1. Participate in meetings or training events required by the Department and/or CTC.

2. CTC Coordinator will assist MAC CTC Specialist and Worcester County MAP in their oversight of the day-to-day operations of this program and all reporting to the Maryland Department of Aging.

3. Serve as a visible and trusted resource where individuals referred to this program may obtain objective information on and access to the full range of long-term service and support options.

4. Provide MAP Options Counseling, including administration of the Level 1 Screen in accordance with the Guidance for Administering the interRAI Level 1 Screen, last updated May 2019, as updated, to individuals referred to this program. Options Counseling, a person-centered planning service, will be provided prior to an individual enrolling in a program or being placed on a waitlist, with the goal of ensuring that the individual’s goals, strengths, and needs are identified by him/her and a comprehensive discussion of available and unavailable options, including existing personal and community resources and assets, is conducted so that the individual is connected to those that best meet his/her identified goals.

5. Ensure that where in-depth expertise or counseling is required (e.g., income benefits counseling, caregiver support, Chronic Disease Self-Management, etc.), individuals referred are connected to the most appropriate programs, services, or specialists.

6. Link consumers with needed services, such as senior center activities, home delivered meals, personal care, respite, Community First Choice, Community Personal Assistance Services, Community Options Waiver, etc., to provide additional support to divert participants from Skilled Nursing and hospital readmissions and improve a participant's Social Determinants of Health.

7. Provide assistance, including completing applications, where requested or necessary to link the individual to identified services and programs, particularly long-term home, and community-based services.

8. For individuals who have been identified as presumptively eligible services, support the individual in completing the eligibility and enrollment process.

9. Work with hospital partners and physician’s care coordination team, including AERS staff, as needed, to ensure the consumer receives targeted, short-term, post-discharge support.

10. Conduct follow-up 30, 60, 90, and 120 days, as consistent with the CTC program model to gather data, determine outcomes and identify whether more assistance is needed.

11. Collect and report data accurately and in a timely manner. Assist with preparation of quarterly data reports using REDCap and CRISP panels.

12. Participate in the Federal Financial Participation (FFP) process, including participation in an initial training to successfully identify relevant codes and utilize the Random Moment Time Study (RMTS) system.

13. Develop and follow the workflow to receive referrals through the hospital partners and physician practices.

14. Outreach with physician practices and Care Transformation Organizations to contract for Evidence Based Health Promotion Programs. Track data and bill accordingly.

15. Continuing education with various IT platforms to provide instruction to program staff and community partners

Job Type: Full-time

Pay: $20.00 - $22.00 per hour

Expected hours: No less than 35 per week

Benefits:

• 401(k) matching
• Health insurance
• Life insurance
• Paid time off

Schedule:

• 8 hour shift
• Monday to Friday

Work setting:

• In-person
• Office

Ability to Relocate:

• Salisbury, MD 21804: Relocate before starting work (Required)

Work Location: In person