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
Company Overview