CCT Transition Coordinator

Libertana is a healthcare organization seeking a Transition Coordinator to assist SNF residents in their transition to community living. The role involves coordinating with various stakeholders to ensure a smooth transition and managing care plans for residents. Responsibilities 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 Skills 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 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 Bachelor's degree in healthcare, business administration or related field preferred 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 Company Overview Libertana is a revolutionary home health and hospice brand. It was founded in 1994, and is headquartered in Beverly Hills, California, USA, with a workforce of 501-1000 employees. Its website is