Coordinator, Care Transitions

ABOUT US

Join us in making a career in Independent Living Systems, an industry leader in managing home and community-based programs for over 20 years. Independent Living Systems, LLC and its subsidiaries offer a comprehensive range of clinical and third-party administrative services to managed care organizations and providers that serve high-cost, complex member populations in the Medicare, Medicaid, and Dual-Eligible Market. ILS provides tailored integrated solutions aimed at improving health outcomes while rebalancing costs, addressing social determinants of health and connecting members with community-based resources.

Position Summary

The Transition of Care Coordinator is responsible for identifying and assisting Skilled Nursing Facility (SNF) enrollees who are potential candidates for transitioning into a community setting. The Transition of Care Coordinator works in collaboration with the Skilled Nursing Facility staff, care managers, enrollees, and families to coordinate proper care and promote a safe and successful transition. Transition of Care Coordinator is also responsible for the monitoring of community enrollees who are receiving short-term rehab services in the SNF to ensure a safe transition back to the community and prevent a reverse transition. This includes assessing the enrollee’s interest, needs, and support as well as developing strategies to overcome and mitigate barriers to a successful transition.

Essential Functions 

Core duties and responsibilities include the following. Other duties may be assigned.

1. Collaborate with the SNF care managers to facilitate transition activities to include:
2. Educate enrollees and their families/representatives about the transition program and assistance available.
3. Identify potential Nursing Home Transitions (NHT).
4. Assess the enrollee’s functional and medical needs.
5. Identify an appropriate community setting.
6. Evaluate the community setting for safety.
7. Ensure LTC services are in place upon discharge.
8. Collaborate with SNF staff to ensure enrollee is discharged with any necessary Medicare covered services.
9. Conduct weekly follow ups on enrollees receiving rehabilitative services in the SNF to develop a plan for safe and appropriate transition back to a community setting.
10. Collaborate with community providers to establish positive partnerships.
11. Participate in weekly interdisciplinary care team meetings to:
    1. Review potential NHTs.
    2. Review status of current NHTs.
    3. Review of enrollees receiving rehabilitative services in the SNF, including discharge plans.
12. Able to meet monthly Nursing Home Transition goal. 

Education and Experience

• Bachelor’s Degree in Social Work, Sociology, Psychology, Gerontology, or a related Social Services field
• Master’s Degree (preferred but not required)
• Registered Nurse, licensed in the State of Florida (preferred but not required)
• Experience in the Long-Term Care Program (preferred but not required)
• Proficiency of Microsoft Office applications including Office, Excel, and Outlook
• Experience/ knowledge in Medicare and Medicaid 
• Knowledge of Federal and State and Statewide Medicaid Managed Care regulations (preferred)
• Bilingual - Spanish/English a plus

Required Skills

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Verbal Communication - Excellent verbal communication skills with the ability to clearly present information orally and/or influence others through oral presentation.
• Written Communication - Excellent written communication skills with the ability to effectively write and extract information from written material.
• Teamwork - Ability to work with people and effectively motivate others to achieve intended goals and objectives.
• Organization and Planning - Ability to prioritize, organize tasks and develop the necessary action plans to accomplish specific goals, within the required timeframes/deadlines.
• Decision Making and Problem Solving - Ability to identify a problem and implement interventions and solutions while exhibiting good sound judgment in the process; ability to take a systematic approach to decision  making by identifying a problem  or deficiency, examining the  cause or barriers, and implementing interventions and improvement strategies.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is occasionally required to stand, walk, sit, use hands, reach with hands, and arms, talk and hear. The employee must occasionally life and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to focus.

Must be able to work in a fast-paced environment.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.

Drug Free Workplace

In compliance with the Drug-Free Workplace Act of 1988, Florida Community Care has a longstanding commitment to provide a safe, quality-oriented, and productive work environment. Alcohol and drug abuse poses a threat to the health and safety of FCC employees and members and to the security of the company's equipment and facilities. For these reasons, FCC is committed to the elimination of drug and alcohol use and abuse in the workplace.

Travel

This position requires up to 70% travel. Travel is primarily local.

EEO STATEMENT 

In compliance with the Drug-Free Workplace Act of 1988, Independent Living Systems has a longstanding commitment to provide a safe, quality-oriented, and productive work environment. Alcohol and drug abuse pose a threat to the health and safety of ILS employees and to the security of the company's equipment and facilities. For these reasons, ILS is committed to the elimination of drug and alcohol use and abuse in the workplace. Independent Living Systems, LLC, and its subsidiaries, including FCC, provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, disability, ancestry, or any other characteristic protected by state, federal, or local law. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.