Community Transition Team staff providing members with aftercare support following a 24-hour care admission. Collaborating with healthcare providers for ongoing care and resource access.
Responsibilities
Provide member support on securing aftercare supports following a 24 hour level of care admission
Requires some in person supports to providers, members, and Emergency department/crisis centers
Provides ongoing, community-based support for an assigned caseload of health plan enrollees
Conducts new enrollee outreach and orientation, arranges appointments and transportation as needed
Assists enrollees in accessing care and ensures care is received
Makes follow up care arrangements and ensures post-hospital care is delivered as planned
Meets with enrollee regularly to monitor progress according to the Care Coordination Plan
Maintains up to date documentation in the Care Coordination Plan and other Health Services tools
Requirements
Experience with individuals who have severe mental illness or chronic medical conditions
Experience in community service, healthcare or social services and/or community-based or home health care experience required
GED, High School Education - Preferred Associate, Bachelor's
DL - Driver License, Valid In State - Other Other License and Certifications - Preferred LPN - Licensed Practical Nurse - Care Mgmt Care Mgmt
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