Transition Coordinator

Where Compassion Meets Innovation And Technology And Our Employees Are Family

Thank you for your interest in joining our team! Please review the job information below.

General Purpose of Job:
The STAR Kids Transition Coordinator understands that the transition to adulthood is one of the most significant events in an individual's life, especially for individuals with disabilities receiving publicly funded services under a children's program. Preparing for adult transition requires significant early planning led by a transition coordinator who assembles a transition team and develops a transition plan with an extensive array of activities to maximize independence and assist the youth in qualifying for the appropriate adult programs.

The STAR Kids Transition Coordinator will oversee and lead all transition activities from initial contact through final transition to STAR+PLUS, other HHSC programs or other community-based programs. The STAR Kids Transition Coordinator is committed to ensuring that all members live in the most integrated residential setting of their choice. In addition, the STAR Kids Transition Coordinator will work with the nursing facility or intermediate care facility to relocate the member back to the community setting of their choice.

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. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by Health Plan leadership, as required.

• Function in an advisory role to the Medical Directors and Medical Management Committee in the following areas:
• Provide evaluation of and assist in the development of quality patient care services offered by DCHP;
• Assist in the establishment of patient care and professional staff policies and procedures of DCHP; and
• Participate in long-range planning of services and/or programs offered by DCHP.
• Assemble a transition team and develop a transition plan with an extensive array of activities to maximize independence and assist the youth in qualifying for the appropriate adult programs for those members who will be aging out of STAR Kids.
• Develop policies, informational material, resource guides, transition assessment, transition readiness, planning/integration into adult services, and transference and admissions support to adult services.
• Oversee and lead all transition activities from initial contact through final transition to STAR+PLUS or other community-based programs.
• Be knowledgeable about children's issues, transition activities, local community resources, Medicaid eligibility, guardianship issues, and working with individuals with complex needs and their families, STAR+PLUS, programs administered by the Department of Aging and Disability Services (DADS), TEA, Department of Assistive and Rehabilitation Services (DARS) and all other relevant state agencies and community-based organizations.
• Conduct a transition assessment that results in a continuity of care plan and checklist that captures all the youth's needs and all necessary and relevant activities are met with no breaks in service or medication availability.
• Identify adult healthcare providers and assist in transitioning member to new provider.
• Work with a nursing facility (NF) or intermediate care facility (ICF) to establish a permanency plan to relocate the Member back to the community setting of their choice.
• Establish communication links with appropriate staff/permanency planners, an effective monitoring schedule, establishing written service plan for safe relocation, and identifying appropriate short-term intensive services/supports for post-relocation community placement to help ensure stabilization.
• Conduct other appropriate assessments according to STAR Kids contract.
• Must be knowledgeable about managed care Medicare/Medicaid criteria/guidelines.
• Must have a working knowledge of various reimbursement mechanisms including third party requirements and Medicare.
• Negotiates with vendors when necessary for services/equipment.
• Ensure appropriate referrals to agencies and assistance programs are completed.
• Complete documentation about a member's plan of care, progress toward meeting care goals, outcomes, case reports, etc.
• Produce status reports on a regular basis to track members in STAR Kids.
• Participates in health plan's performance improvement activities.
• Participates in health plan committees as appropriate and on request.
• Communicates with management regarding status of current workload and turn-around time discrepancies as necessary. Must obtain approval from manager or designee to any redistribution of workload.
• Ensure thorough knowledge of the STAR Kids…