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Job Description JOB DESCRIPTION Position: Transition Coordinator Pay Range: $24.00-$30.00 PER HR Reporting To: CCT Manager Work Type: Remote/Field POSITION SUMMARY: The Transition Coordinator is responsible for coordinating the options that are available to SNF residents. The Transition Coordinator is responsible for assisting in the liaison work between the State of California and the Community in which clients from local nursing facilities will reside. The Transition Coordinator will represent Libertana Home Health as the Lead Organization that covers Los Angeles, Kern, Riverside, San Bernardino, Orange, Ventura, Santa Barbara, San Luis Obispo, Fresno, Imperial and San Diego Counties. QUALIFICATIONS: • Bachelor’s degree in healthcare, business administration or related field preferred., • Intermediate personal computer skills, including Microsoft Word, Excel, PowerPoint and Access., • Previous Health Care experience preferred., • Background and/or knowledge of developing reports, newsletters, brochures, statistics, and information analysis desired., • Experience in Community Liaison in the Los Angeles community., • Is at least 18 years of age., • Must have adequate physical and mental health., • Ability to read, write and follow instructions in English., • Maintains good organizational skills., • Self-directed and able to work with minimal supervision., • possesses excellent analytical skills., • Ability to establish and maintain good communication and relationships with all office, field and administrative personnel., • Effective written and verbal communications skills. ESSENTIAL DUTIES AND RESPONSIBILITIES: The following is a representation of the major duties and responsibilities of this position. Libertana Home Health will provide reasonable accommodation to allow otherwise qualified applicants with disabilities to perform essential functions. • Assists clients with housing and transition coordination., • Follows up with SNF case managers, discharge planners and/or representatives, establishing working relationships and educating them about the CCT program and the variables available to their patients/clients on discharge., • Identifies and interviews residents for pre-screening and isolates client needs., • Performs phone calls to clients/SNF’s at least 1 month prior to discharge from “Waitlist” to gather documentation and start identifying possible RCFE Placements., • Coordinates agency RN visits to assess resident and to help prepare Initial Care Plan (ICP)., • Completes the Initial Care Plan (ICP) and submits to DHCS for review., • Prepares and submits 20-hour TAR with appropriate attachments. Prepares and submits the 100 TAR., • Works on housing and other needs of the resident. Coordinates DME and assistive devices with SNF and DME Company., • Maintains contact with SNF’s and residents while working on the resident’s care plan and other needs., • Applies for appropriate waiver based on the resident’s needs (ALW/NF/IHSS)., • Works on Final Care Plan (FCP), obtains physician signature, and attaches to PTC TAR., • Obtains transition plan signatures on date of transition and attaches to PTC TAR., • Helps resident transition back into the community as outlined in ICP., • Assures continuance of PTC to provide case management to be followed for the first year at home., • Presents all time keeping to billing department weekly., • Knowledge of confidentiality, HIPAA and healthcare laws and regulations., • Maintains proper timekeeping., • Maintains all required credentials up to date., • Reports fraud and abuse., • Knowledge of mandated reporting., • Conducts timely recording and/or documentation of all client contact., • Attends all state mandated in-service trainings., • Driving may be required to geographical areas that are covered by the company., • Performs other duties as assigned. PHYSICAL REQUIREMENTS: • Stand, sit, talk, hear, and use of hands and fingers to operate computer, telephone, and keyboard on a frequent basis up to 40% of the time., • Reach, stoop, kneel and bend up to 20% of the time, • Moderate amount of walking up to 15% of the time., • Moderate amount of driving up to 25%of the time., • Close vision requirements due to computer work on a frequent basis, • Light to moderate lifting may be required up to 25lbs on a frequent basis., • Pushing and pulling up to 25lbs.