LOCATION: Remote – this is a home-based, virtual position that operates Monday-Friday from 8:30am - 5:00pm EST. Must live in Vaya’s catchment area. The person in this role is required live 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 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 desire to be rehoused, rather the member/recipient is at risk of losing housing their current placement or has 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 members/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 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 Prevention:

Post TC is required to support members/recipients with maintaining their ongoing PSH by reducing separation risk. The stratification category directs the goals and subsequent tasks the Post TCs complete with providers to support member/recipient. Members/recipients stratified to medium or high require Separation Risk prevention. The Post TC will open the member to the Separation Risk program and add the member/recipient to the Pre-Separation Huddle on host ongoing Treatment Team Meetings until the tenancy concern has been resolved. The Post TC much

Documentation:

Post TC is required to provide clear and concise documentation of the post transition phase for each member/recipient under TCL. This documentation will serve to inform the local organization, state, and federal government. All contacts and interventions will be documented in the member/recipient’s Electronic Health Record (EHR) and the Transitions to Community Living Database (TCLD). Post TC is required to review the Community Inclusion Monthly Update (CIMU) forms and payee client statements to ensure the member/recipient is not at risk of losing housing or financial assistance. All documentation and notes are required to be uploaded into the member/recipient's record within 24 hours. All receipts, items received form, and invoice payment request stamps are required to be uploaded and/or submitted to Vaya's Finance team within 48 hours. Post TC is also required to maintain good record keeping ensuring that TCL is in compliance with NCDHHS required Root Cause Analysis (RCA) reporting and document additional triggering event reporting as needed. The Post TC must support maintaining the Master Spreadsheet (MSS) to maintain data entries for members/recipients assigned to their caseload to reflect current participant data points.

Collaboration:

The Post TC will have ongoing, respectful communication with all members/recipients involved in the post transition and/or rehouse phase. The Post TC will work closely with the transition coordinators, housing - transitions, care coordination, provider network, TCL Community Liaison, hospital liaisons and other Vaya departments necessary to create, implement and successfully support members/recipients with maintaining TCL permanent supported housing. The Post TC will also be involved in education with members/recipients, LRP (Legally Responsible Person), families, providers, and stakeholders associated with Transitions to Community Living.

Financial Reassessments:

The Post TC will complete four (4) month reassessments by completing a CLA budget worksheet and CLA application to ensure the members/recipients meet ongoing CLA eligibility. The Post TC will ensure the member/recipient has an active Social Security application or application on file. The Post TC will work with the members/recipients provider to ensure they continue to appeal any SSA denials. The Post TC will confirm ongoing CLA monthly payments to ensure Vaya's Finance team has the correct information to process payments monthly. The Post TC ensures the MSS accurately reflects that's the ongoing CLA amount.

The Post TC will support the Special Assistance In-Home (SA-IH) designated staff with coordination of SA-IH annual recertification documentation (FL2 forms and SAIH Attestation forms) and provider linkage as needed. If SA-IH is discontinued for any reason the Post TC will support the members/recipients with getting reconnected with SAIH funds by supporting with SA-IH application, obtain current FL2 form, and the Appendix E Supplement 2 form. The Post TC will ensure that all required SA-IH documents have been saved in the members/recipients EHR and MSS.

The Post TC will support the Housing team by calling the members/recipients or provider to support with completing obtaining TCLV Biennials Recertification when they have been unable to receive a complete TCLV Biennials Recertification from the members/recipients

Other duties as assigned.

KNOWLEDGE, SKILLS, & ABILITIES

A high level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance. This will require exceptional interpersonal skills, highly effective communication ability, and the propensity to make prompt independent decisions based upon relevant facts. Problem solving, negotiation, and conflict resolution skills are essential to balance the needs of both internal and external customers. Must be highly skilled at shifting between macro and micro level planning, maintaining both the big picture and seeing that the details are covered.

The Post TC must have considerable knowledge of the MH/SU/IDD service array provided through the network of Vaya providers. Additional knowledge in Vaya’s Tailored Plan, State funded services, Medicaid B and C waivers and accreditation is helpful.

The employee must be detail oriented, able to organize multiple tasks and priorities, and to effectively manage projects from start to finish. Work activities quickly change according to mandated changes and changing priorities within the department. The employee must be able to change the focus of his/her activities to meet changing priorities.

Proficiency in Microsoft Office products (such as Teams, Word, Excel, Outlook, PowerPoint, etc.) and Vaya information system is required.

EDUCATION & EXPERIENCE REQUIREMENTS

A Bachelor’s Degree in a Human Services field and two years of full-time, post-bachelor’s degree accumulated experience with the population served.

A Bachelor’s Degree in a field other than Human Services and four years of full-time, post-bachelor’s degree accumulated experience with the population served.

PHYSICAL REQUIREMENTS

Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
Mental concentration is required in all aspects of work.

RESIDENCY REQUIREMENT: The person in this position is required to reside in North Carolina or within 40 miles of the North Carolina border.

SALARY: Depending on qualifications & experience of candidate. This position is non-exempt and is eligible for overtime compensation.

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visithttps://www.vayahealth.com/about/careers/.

Vaya Health is an equal opportunity employer.

Vaya Health

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Post Transition Coordinator - QP (Remote NC)