Health Guide- Community Transition Team

Magellan Health•Norristown, PA

About The Position

In this position, the Community Transition Team staff are dedicated to Magellan members to provide member support on securing aftercare supports following a 24 hour level of care admission. Will require some in person supports to providers, members, and Emergency department/crisis centers to assist in discharge planning. Provides ongoing, community-based support for an assigned caseload of health plan enrollees to improve access to care and care coordination. Establishes a relationship with the enrollee, the care coordination team, and providers. Conducts new enrollee outreach and orientation, arranges appointments and transportation as needed. Assists the enrollee in learning to navigate the health care delivery system, community resources, transportation, and effectively use health plan benefits. Conducts outreach and orientation for new enrollees. Gathers information needed to ensure continuity of care and permission to share information. Administers Health and Wellness Questionnaire. Seeks connection by working with the Peer Support Specialist and leveraging community services, care providers, family members, schools, etc. Assists enrollees in accessing care and ensures care is received. Helps members, as needed, in selecting providers, making appointments, and planning transportation. Contacts enrollee or provider to ensure appointments have occurred. Assists in transitions of care to and from alternative levels of care or settings. Makes follow up care arrangements and ensures post-hospital care is delivered as planned. Meets with enrollee regularly (as determined by individual risks) in order to monitor progress according to the Care Coordination Plan. Reminds enrollee of self-management tools and crisis support. Informs and engages the Care Coordination Team if enrollee has difficulty adhering to the care coordination plan or adhering to treatment and needs additional support. Works with enrollee and family/supports to engage in socialization, work or volunteer related activities, or access community resources and services. Maintains up to date documentation in the Care Coordination Plan and other Health Services tools. Prepares information for Care Coordination Team meetings and as requested, for shared treatment planning sessions. The job duties listed above are representative and not intended to be all-inclusive of what may be expected of an employee assigned to this job. A leader may assign additional or other duties which would align with the intent of this job, without revision to the job description.

Requirements

Experience with individuals who have severe mental illness or chronic medical conditions.
Experience in community service, healthcare or social services and/or community-based or home health care experience required.
DL - Driver License, Valid In State - Other

Nice To Haves

LPN - Licensed Practical Nurse - Care MgmtCare Mgmt

Responsibilities

Provide member support on securing aftercare supports following a 24 hour level of care admission.
Provide in person supports to providers, members, and Emergency department/crisis centers to assist in discharge planning.
Provide ongoing, community-based support for an assigned caseload of health plan enrollees to improve access to care and care coordination.
Establish a relationship with the enrollee, the care coordination team, and providers.
Conduct new enrollee outreach and orientation, arranges appointments and transportation as needed.
Assist the enrollee in learning to navigate the health care delivery system, community resources, transportation, and effectively use health plan benefits.
Conduct outreach and orientation for new enrollees.
Gather information needed to ensure continuity of care and permission to share information.
Administer Health and Wellness Questionnaire.
Seek connection by working with the Peer Support Specialist and leveraging community services, care providers, family members, schools, etc.
Assist enrollees in accessing care and ensures care is received.
Help members, as needed, in selecting providers, making appointments, and planning transportation.
Contact enrollee or provider to ensure appointments have occurred.
Assist in transitions of care to and from alternative levels of care or settings.
Make follow up care arrangements and ensures post-hospital care is delivered as planned.
Meet with enrollee regularly (as determined by individual risks) in order to monitor progress according to the Care Coordination Plan.
Remind enrollee of self-management tools and crisis support.
Inform and engage the Care Coordination Team if enrollee has difficulty adhering to the care coordination plan or adhering to treatment and needs additional support.
Work with enrollee and family/supports to engage in socialization, work or volunteer related activities, or access community resources and services.
Maintain up to date documentation in the Care Coordination Plan and other Health Services tools.
Prepare information for Care Coordination Team meetings and as requested, for shared treatment planning sessions.