MFP Transition Coordinator

LOCATION: Remote - must live in or near Rockingham, Caswell, Person, Granville, Warren, Guilford, Alamance, Durham, Franklin, Wake, Johnston, Lee, Chatham, or Randolph County, North Carolina. Travel is required throughout these counties for this position .

GENERAL STATEMENT OF JOB

The Money Follows the Person (MFP) Rebalancing Demonstration Grant helps states rebalance their Medicaid long- term care systems. The Transition Coordinator leads a participant and the planning team through a planning process and ensures the participant has the supports in place to live successfully in the community. Strong collaboration with other community partners is essential for quality transition planning.

The MFP Transition Coordinator will play a critical role in facilitating the transition of eligible older adults and adults with physical disabilities from long-term care facilities to community-based living arrangements. This role requires a deep understanding of person-centered planning, the ability to coordinate various community-based services and supports, and strong collaboration skills with other community partners to ensure quality and effective transition planning.

ESSENTIAL JOB FUNCTIONS

Transition Coordination:

• Collaborate with transition partners to ensure the quality, efficiency, and integrity of the transition process for each MFP participant.
• Serve as the team lead for each participant's transition team, assigning tasks, monitoring completion, reporting status changes, and reassessing as needed.
• Secure and coordinate resources and supports to enable participants to live as independently as possible in the community.
• Ensure critical benefits and supports, such as Social Security payments, SNAP benefits, public transportation, utility services, and other benefits, are in place prior to transition.
• Maintain required documentation for each transition, including transition needs budget, preliminary and final transition plan, MFP Transition Checklist, and monthly database updates.

Post-Transition Support:

• Provide follow-up support in-person and virtually for a minimum of one year post-transition.
• Continue monitoring each MFP participant's budget for up to one year post-discharge to ensure as many needs as possible are met using available funds.
• Collaborate with Long-Term Care Ombudsman, Local Contact Agencies, and other community
• organizations to provide outreach about transition services.

Communication and Collaboration:

• Participate in multiple monthly conference calls with other transition coordinators, Division of
• Vocational Rehabilitation (DVR), other transition coordination partners, and MFP staff.
• Work closely with other Vaya staff including managers, supervisors, care coordination, hospital liaisons, and other departments necessary for successful transition planning.

Documentation and Reporting:

• Document the in-reach and transition progress accurately and clearly to inform local, state, and federal agencies.
• Ensure all contacts and interventions with participants are documented in the consumer's administrative health record.
• Ensure that all required documentation and reports are submitted to manager prior to deadlines.

Other Duties as Assigned:

Perform other related duties as required.

KNOWLEDGE, SKILL & ABILITIES

A high level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance. This will require exceptional interpersonal skills, highly effective communication ability, and the propensity to make prompt independent decisions based upon relevant facts. Problem solving, negotiation, and conflict resolution skills are essential to balance the needs of both internal and external customers. Must be highly skilled at shifting between macro and micro level planning, maintaining both the big picture and seeing that the details are covered.

The MFP Transition Coordinator must have considerable knowledge of the MH/SU/IDD service array provided through the network of Vaya providers. Additional knowledge in Vaya Medicaid B and C waivers and accreditation is helpful.

The employee must be detail oriented, able to organize multiple tasks and priorities, and to effectively manage projects from start to finish. Work activities quickly change according to mandated changes and changing priorities within the department. The employee must be able to change the focus of his/her activities to meet changing priorities.

Proficiency in Microsoft Office products (such as Word, Excel, Outlook, PowerPoint, etc.) and Vaya information system is required.

QUALIFICATIONS & EDUCATION REQUIREMENTS

• A Bachelor's degree, in a human services or related field preferred, and at least two years of full-time accumulated related experience

OR

• A Master's degree in a human services or related field, and at least one year of related experience.

This position plays a vital role in advancing the mission of the MFP program, supporting individuals to transition from institutional settings to living independently in their communities with the necessary supports. The ideal candidate will have a strong background in human services, excellent organizational skills, and a commitment to promoting the well-being of vulnerable populations. Related experience includes:

1. Transition coordination;
2. Working with older adults;
3. Working with people with physical disabilities;
4. Delivering care to individuals with chronic conditions requiring long-term
   services and supports;
5. Working with individuals moving from one facility-based setting to another
   setting (e.g., community-based or facility-based);
6. Case Management;
7. Social work;
8. Nursing;
9. Or other similar experience

PHYSICAL REQUIREMENTS

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
• Mental concentration is required in all aspects of work.

RESIDENCY REQUIREMENT: This position is required to reside in North Carolina or within 40 miles of the North Carolina border.

SALARY: Depending on qualifications & experience of candidate. This position is non-exempt and is eligible for overtime compensation.

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit

Vaya Health is an equal opportunity employer.