Job Description
LOCATION Remote - this is a home-based virtual position that operates Monday-Friday from 8:30am - 5:00pm EST. Incumbent may live in or near Vaya's catchment area. The person in this role is required to maintain residency in North Carolina or within 40 miles of the NC border. GENERAL STATEMENT OF JOB The Post Transition Coordinator – QP (Post TC) is responsible for providing proactive intervention and coordination of services and resources to persons residing in & maintaining their home or who wish to be rehoused as part of the Transitions to Community Living (TCL) program. The Post TC must understand the Olmstead Act and embrace the housing first model. The Post TC must enjoy problem‑solving, can adapt to changing circumstances, adjust plans easily, be willing to change your approach or perspective when needed, and be able to work in a fast‑paced environment to maintain a caseload. Post Transition activities support individuals with maintaining their home in the community setting. They assist with promoting community inclusion, employment, and ensuring the appropriate level of services and supports are in place to ensure ongoing tenancy for the individual. These services support members/recipients with maintaining a home in the community of their choice. This is a remote position with work being completed in home/Vaya office. The Post Transition Coordinator will coordinate services/supports via Vaya technology, in collaboration with internal/external stakeholders. Note: This position requires access to, and use of confidential healthcare information or protected health information (PHI) as described in laws addressing patient confidentiality, including, but not limited to, the federal HIPAA law, the Confidentiality of Alcohol and Substance Abuse Patient Records law, 42 CFR Part 2, and various state laws. As such, the individual filling this position shall be required to be trained regarding such laws and shall be required to observe those laws in his/her capacity as an employee of Vaya Health. The individual filling this position shall also sign a confidentiality statement as an employee of Vaya Health. ESSENTIAL JOB FUNCTIONS Post Transition Planning The Post TC supports members/recipients after they have moved into their unit. The Post TC's main objective is to, in partnership with the member/recipient's behavioral health provider and care management, successfully retain participants in their community. After thirty (30) days of a member/recipient's transition into their TCL home, the participant is assigned to the Post TC for continued support. The Post TC utilizes the Post Transition Stratification that specifies triggers to stratify members/recipients in either high, medium, or low categories. The stratification category directs the goals and subsequent tasks the Post TCs complete with providers to support the member/recipient. Each member/recipient is identified as low stratification to start and once they meet certain stratification criteria they are escalated to medium or high stratification and opened to the T&H Separation Risk program and/or the T&H Rehousing program. This triggers a staffing at the Pre-Separation Huddle until the criteria is resolved returning them back to a low stratification and the T&H Separation Risk program closes. Rehousing The Post TC supports members/recipients who desire to be rehoused, rather than remaining at risk of losing their current placement or having the desire to move to a new location. The Post TC goal is to reduce or prevent separations by rehousing the member/recipient when possible. Members/recipients who are at risk will collaborate with the provider(s) to alleviate issues to help keep them housed. According to the service definition, the provider(s) supports participants with identifying other housing options when they are losing their current residence and need to move to another location. The Post TC must determine which path is required with a gap or without a gap and will follow the process for either workflow. The Post TC must lead ongoing Treatment Team meetings with the member/recipient and the member/recipient care team until housing has been identified. The Post TC must determine if a Rehouse Plan is needed. If needed, the Post TC must ensure that the Rehouse Plan is completed by the provider and that the member/recipient is supportive to help the member maintain the PSH placement once new housing options have been identified. The Post TC must complete the appropriate subsidy documentation and request the correct funding as financial needs arise to rehouse the member/recipient. If a participant is not interested in being rehoused with TCL, Post TC should document their efforts, document the participant's informed decision, and send a request to their supervisor for the participant to be considered for withdrawal. Separation Risk