Social Worker - Community Transitions

GENERAL SUMMARY

Under the general supervision of the VP / COO, or designee, the Transition Navigator conducts and tracks Transition Services activities, tracks and prepares referral reports, tracks billable units and submits billing and claims. This role requires the use of person-centered planning principles to assist individuals in transitioning from nursing facilities to a community-based setting.

RESPONSIBILITIES AND DUTIES

• Utilize person-centered planning principles to assess and determine program eligibility for individuals who are Medicaid-eligible and have a barrier to discharge.
• Conduct face-to-face introductory meetings and provide a program information packet to individuals.
• Perform a face-to-face Community Transition Assessment (CTA) to determine the individual's needs and preferences and evaluate potential issues that may affect their transition plan.
• Develop a comprehensive Person-Centered Service Plan with participants and their supports, ensuring it addresses projected costs and barriers to transition. Ensure participants, guardians, and family members are actively involved in the service planning process.
• Shop for household goods and services and be physically present on day of move to assist participant with set up and ensure all needs are met.
• Provide pre-transition Housing Transition Services by assisting with housing search, application processes, and preparing the living environment for move-in.
• Implement and monitor the Person-Centered Service Plan, including linking individuals to home and community-based services (HCBS) and continuously updating the plan as needs change. Monitor the delivery of services and supports to achieve participant goals.
• Report critical incidents and remediation plans or processes to the Michigan Department of Health and Human Services (MDHHS) according to MDHHS policy and guidelines.
• Maintain contact and professional relationships with assigned nursing facility staff and other collaborative partners such as local MI Choice waiver agencies, Area Agencies on Aging, and Centers for Independent Living.
• Respond to information requests from MDHHS and cooperate with case record reviews.
• Submit prior authorizations to MDHHS through CHAMPS for transition services.
• Provide Adverse Action Notices to participants when services are terminated, suspended, or reduced, or when a request is denied.
• Conduct a post-transition CTA within 30 days to evaluate the new living arrangement and services.
• Track all referrals in the Nursing Facility Transition (NFT) Portal in COMPASS, input participant information, and upload required documents.
• Document all service activity and phone contact per contract requirements.
• Maintain billable units at 50 - 60% of monthly workload. Submit billable units monthly to supervisor. Complete billing and submit claims by the 10th of the month following services.
• Coordinate care with Highly Integrated Dual Eligible Special Needs Plans (HIDE SNPs) to ensure continuity of care for individuals receiving services from both organizations.
• Direct enrollees to the HIDE-SNP's grievance and appeal process as appropriate.
• Protect the confidentiality of all participant information and maintain it in controlled access files for at least six years.
• Participate in transition training and project coordination meetings as scheduled.

REQUIRED KNOWLEDGE, SKILLS, ABILITIES

EDUCATION AND EXPERIENCE