LTSS Care Transition Nurse (SEGUIN)

POSITION SUMMARY/RESPONSIBILITIES

The Transition Specialist, RN, contributes to the Long Term Services and Supports (LTSS) service coordination process by performing activities within the scope of licensure; provides supervision and direction to staff participating in Member’s cases following applicable state law and contract; develops, monitors, evaluates, and revises the Members’ care plans to meet Member’s needs, to optimize health care across the care continuum to enhance the Member's well-being, independence, integration in the community, and potential for productivity. The Transition Specialist, RN, conducts a holistic assessment of the Member's dynamics, needs, and preferences while providing education and health-related information to the Member, the Member’s Legal Authorized Representative (LAR), and the Member’s Support Network. Responsible for the coordination of STAR+PLUS Members' covered and non-capitated services, including acute and LTSS, while meeting the Member's physical, behavioral, functional, and psychosocial needs. Complies with policies, procedures, and protocols for establishing and maintaining good working relationships with co-workers, employees, patients, and guests

EDUCATION/EXPERIENCE

Graduation from an accredited school of professional nursing or social work is required. BSN is required . Four (4) recent years of clinical experience preferred, which may include service coordination, case management, quality management, or managed care experience. Working knowledge of HMO standards, LTSS, and NCQA standards is preferred. Knowledge of Medicare and Medicaid HMO experience is preferred. Experience in meeting the needs of vulnerable populations who have chronic, complex conditions, with serious and persistent mental illness (SPMI), lived experience of mental illness or both, and helping people transition from institutional settings to the community is preferred. Individuals selected for these positions must complete training specified by HHSC and demonstrate knowledge and skills delivering the Transition Specialist pilot interventions. Bilingual, English/Spanish, is preferred

LICENSURE/ CERTIFICATION

A current, unrestricted license to practice professional nursing issued by the State of Texas is required. RUG Certification is required and must be obtained within 30 days of employment for all RN candidates