Transition Coordinator – Take Me Home, West Virginia

Reporting to the Take Me Home, West Virginia Transition Manager, the Transition Coordinator will be responsible for assisting people with chronic conditions and disabilities as they move from institutions back into the community using community-based services and supports. Take Me Home, West Virginia is looking to fill two Transition Coordinator positions; one to cover the northern half of the State and another to cover the Eastern Panhandle specifically.

Responsibilities of the Transition Coordinator position include working closely with the Take Me Home, West Virginia Transition Manager and leading participant’s and the planning team through a planning process and ensures the participant has the supports in place to live successfully in his or her community. The Transition Coordinator’s task will vary from transition to transition. To succeed in this role, the Transition Coordinator should have considerable knowledge of Medicaid, aging and disability related issues and services, and program planning, as well as excellent time management and communication skills.

Coordinators will work one-on-one with qualified residents and their Transition Teams to:

• Conduct interviews to share information about options for returning to the community, including the availability of MFP demonstration and Waiver Community Transition Services;
• Assess and verify the resident's readiness to participate in transition assessment and planning;
• Assess participants' transition support needs, including risk factors that may jeopardize a safe and successful transition to the community;
• Facilitate the development of a Transition Team consisting of the facility resident, the Transition Coordinator, the Waiver Case Manager, the facility social worker and other appropriate staff and anyone else the resident chooses to include in the transition process;
• Work with the facility resident and his/her Transition Team to develop a written Transition Plan which incorporates specific services and supports to meet identified transition needs;
• Conduct a Risk Analysis and develop a written Risk Mitigation Plan to address and monitor all identified risks that may jeopardize the resident's successful transition. (This Risk Mitigation Plan will be incorporated into the Waiver Service Plan);
• Arrange and facilitate the procurement and delivery of needed transition services and supports including MFP demonstration services and Waiver Community Transition Services prior to transition. Waiver transition services may include Pre-transition Case Management and Community Transition Services which are one-time services such as utility and security deposits, basic furnishings, accessibility modifications, etc.;
• Conduct outreach to facilitate referrals to the program, and;
• Serve as a liaison with nursing facilities and other long-term care facilities to foster effective communication with facility staff and troubleshoot any issues that may create barriers to a safe and successful transition.

Transition Coordinators will also be responsible for:

• Attending and participating in all scheduled meetings ;
• Attending and participating in educational and training sessions to develop knowledge and skills related to transitioning individuals from long-term facility-based care to the community;
• Complying with all procedures and documentation requirements outlined in the TMH procedures manual, and;
• Meet annual transition benchmarks as established by BMS/TMH

Desirable Education and Experience:

• Bachelor’s Degree in human service-related field and at least two (2) years of relevant experience in long-term care services: or
• Direct work experience in supporting, the transitioning of individuals from long-term facility-based care to the community may be substituted.

Special Requirements:

• Possession of a valid West Virginia driver’s license and access to a car on a regular basis required in the performance of work.
• Live within West Virginia and be able to report to the Take Me Home office, located in Charleston, WV when required.

Job Type: Full-time

Pay: $37,500.00 - $40,000.00 per year

Benefits:

• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift

Ability to Relocate:

• Morgantown, WV: Relocate before starting work (Required)

Work Location: On the road