Health Guide- Community Transition Team - R00000049374 DESCRIPTION/RESPONSIBILITIES:In this position, the Community Transition Team staff are dedicated to Lehigh and Northampton 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. Other Job RequirementsResponsibilitiesExperience in community service, health care or social services and/or community-based or home health care experience required, Experience with individuals who have severe mental illness or chronic medical conditions. General Job InformationTitleHealth Guide- Community Transition Team Grade19 Work Experience - RequiredClinicalWork Experience - PreferredManaged HealthcareEducation - Required Education - PreferredAssociates, Bachelors License and Certifications - RequiredDL - Driver License, Valid In State - Other License and Certifications - PreferredLPN - Licensed Practical Nurse - Care Mgmt Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures. Equal Opportunity Employer-minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity
