Libertana · 1 week ago
CCT Transition Coordinator
Los Angeles, CA
Full-time
Hybrid
New Grad, Entry Level
$24/hr - $30/hrLibertana 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.
Elder CareFranchiseHealth Care
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
Qualification
Required
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
Preferred
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
Libertana
Libertana is a revolutionary home health and hospice brand.
Founded in 1994
501-1000 employees
Funding
Current Stage
Late StageLeadership Team
Neil Rotter
Chief Executive Officer
Hillary Falkai, LCSW
Social Worker-Libertana Care Partners Pediatric Palliative Care
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