MHSU State Hospital Transition Coordinator (Raleigh, NC)

Primary Purpose of Position:   This position will act as the Division of State Operated Healthcare Facilities (DSOHF) Admissions to Discharge Manager as outlined in the Tailored Plan. This position is responsible for overseeing the provision of proactive intervention and care management (treatment planning, assessment, referral/linkage, and monitoring) to individuals admitted to state psychiatric hospitals or ADATC facilities. This position will support and monitor n the transition efforts of members’ assigned Care Manager. This position will also serve as the liaison with NC DSOHF officials. This is a mobile position with work done in a variety of locations. Travel is an essential function of this position.

Role and Responsibilities:  

• Develop relationship with state hospitals and ADATC facilities and facilitate daily communication
• Provide education about available MH/SU/IDD services and supports, as well as education about types of Medicaid and State funded services
• Provide clinical guidance to care managers assigned to members in DSOHF facilities regarding discharge/transition planning.
• Support, assist, and monitor the assigned care manager with the following activities:

o    Link to needed behavioral health and physical health care services and

o    Link to benefits

o    Participate in treatment teams at the state facilities for Partners members

o    Participate in Person Centered Planning, as indicated and if working with children, participate in Child and Family Team meetings

o    Identify gaps in needed services and intervene to ensure the consumer receives appropriate care

o    Identify community resources in collaboration with stakeholders

• Maintain accurate tracking and data information for care coordination activities
• Advocate for members residing in state facilities
• Track and report team performance measures to manager. Assist supervisors and managers with data collection for monthly, quarterly and annual reports.
• Acts as a liaison between the Care Managers and state facilities as needed to ensure continuity of care and successful discharge of member during transition from inpatient stay at the state facility: up to 90 days
• Provide clinical planning assistance to team, MHSU providers, physical health, specialist and pharmacy to
• ensure the members services prevent further hospitalizations and increased quality of life.
• Complete required documentation in TruCare
• Provide education, referrals, care management activities surrounding available servies and supports including Physical Health, Behavioral Health, I/DD, LTSS, TBI, Pharmacy, Vision and Dental services/supports
• Link to needed behavioral health and physical health care services and facilitating appropriate connections to primary healthcare services through Community Care of North Carolina, the Health Department, or other community health resources
• Coordinating and linking members to benefits
• Complete initial and yearly Care Management Comprehensive Assessment and Care Plan
• Conduct Care Team Meetings and ensure treatment team members participate in treatment team meetings to address the needs of the member, first meeting post discharge from state facility
• Conduct continues monitoring of progress toward goals identified in Care Plan through in-person and collateral contacts with the member and member’s supports, including family, information and formal caregivers and routine care team reviews
• Identify the gaps in needed services and intervene as needed to ensure the member receives appropriate care
• Identify and refer member to community resources
• Oversee care transitions for members who are moving from one clinical setting to another
• Maintain accurate tracking and data information for care management activities and outcome including tracking of individuals in and out of services, those who are on waiting lists, those who need follow-up, and those on outpatient commitment

Committees and Meetings:  

• Attend meetings as needed to stay informed of changes in local, State, Federal and Division requirements.
• Participate in assigned committees and quality improvement projects.

Collaboration

• Serve as a collaborative partner in identifying system barriers through work with community stakeholders
• Work in partnership with other LME/MCO departments to address identified needs within the catchment 

Knowledge, Skills and Abilities: 

• Considerable understanding of the Diagnostic and Statistical Manual of Mental Disorders (current version)
• Considerable knowledge of the MH/SU/IDD service array provided through the network of the LME/MCO’s providers
• Knowledge of LME/MCO’s implementation of the 1915(b/c) waivers and accreditation
• Highly skilled at assuring that both long and short-range goals and needs of the individual are addressed and updated, while assuring through monitoring activities that service implementation occurs appropriately
• Exceptional interpersonal and communication skills
• Excellent computer skills including proficiency in Microsoft Office products (Word, Excel, Outlook, and PowerPoint)
• Excellent problem solving, negotiation, arbitration, and conflict resolution skills
• Detail-oriented, able to organize multiple tasks and priorities and effectively manage projects from start to finish
• Ability to make prompt independent decisions based upon relevant facts, to establish rapport and maintain effective working relationships
• Ability to change the focus of his/her activities to meet changing priorities
• A high level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance

Education/Experience Required:   Master’s-level fully Licensed Clinical Social Worker (LCSW), fully Licensed Clinical Mental Health Counselor (LCMHC), fully Licensed Psychological Associate (LPA), or bachelor’ s level registered nurse (RN) plus one (1) year of experience working directly with individuals with serious mental illness (SMI). Must have ability to travel regularly as needed to perform job duties. Must reside in North Carolina.

Education/Experience Preferred:   Prior care management experience. Prior project/program management or coordination experience.

Licensure/Certification Requirements:    Current unrestricted license (LCMHC, LCSW, LPA, or RN) with the appropriate professional board of licensure in the state of North Carolina. Employee is responsible for complying with respective licensure board’s continuing education/training requirements in order to maintain an active license.