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.ResponsibilitiesAssists clients with housing and transition coordinationFollows 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 dischargeIdentifies and interviews residents for pre-screening and isolates client needsPerforms phone calls to clients/SNF’s at least 1 month prior to discharge from “Waitlist” to gather documentation and start identifying possible RCFE PlacementsCoordinates 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 reviewPrepares and submits 20-hour TAR with appropriate attachments. Prepares and submits the 100 TARWorks on housing and other needs of the resident. Coordinates DME and assistive devices with SNF and DME CompanyMaintains contact with SNF’s and residents while working on the resident’s care plan and other needsApplies 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 TARObtains transition plan signatures on date of transition and attaches to PTC TARHelps resident transition back into the community as outlined in ICPAssures continuance of PTC to provide case management to be followed for the first year at homePresents all time keeping to billing department weeklyKnowledge of confidentiality, HIPAA and healthcare laws and regulationsMaintains proper timekeepingMaintains all required credentials up to dateReports fraud and abuseKnowledge of mandated reportingConducts timely recording and/or documentation of all client contactAttends all state mandated in-service trainingsDriving may be required to geographical areas that are covered by the companyPerforms other duties as assignedSkillsIs at least 18 years of ageMust have adequate physical and mental healthAbility to read, write and follow instructions in EnglishMaintains good organizational skillsSelf-directed and able to work with minimal supervisionPossesses excellent analytical skillsAbility to establish and maintain good communication and relationships with all office, field and administrative personnelEffective written and verbal communications skillsKnowledge of confidentiality, HIPAA and healthcare laws and regulationsMaintains proper timekeepingMaintains all required credentials up to dateReports fraud and abuseKnowledge of mandated reportingConducts timely recording and/or documentation of all client contactAttends all state mandated in-service trainingsDriving may be required to geographical areas that are covered by the companyBachelor's degree in healthcare, business administration or related field preferredPrevious Health Care experience preferredBackground and/or knowledge of developing reports, newsletters, brochures, statistics, and information analysis desiredExperience in Community Liaison in the Los Angeles communityCompany OverviewLibertana 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 http://libertana.com/.



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