Care Transition Program Coordinator

AREA AGENCY ON AGING OF NORTHWEST MICHIGAN

Make a difference in the lives of older adults, caregivers and adults with disabilities! The Area Agency on Aging of Northwest Michigan seeks an energetic, highly organized, experienced Care Transition Coordinator.

The Area Agency on Aging of Northwest Michigan (AAANM) is the place to turn for assistance with complex issues facing older adults, adults with disabilities and caregivers. AAANM links to, coordinates with, and provides a variety of programs, services, and resources within the 10-county service area of northwest Michigan. AAANM is a nonprofit corporation operating as a designated Area Agency on Aging by the Michigan Department of Health and Human Services and is a Medicaid MI Choice Waiver agent.

Mission Statement: Our mission is to serve and advocate for older adults, persons with disabilities and caregivers by supporting their independence, dignity, and quality of life.

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The Care Transition Coordinator is responsible for the day-to-day coordination, implementation, and ongoing operation of the CTCS Program. The Coordinator provides program-level oversight while also delivering direct Community Health Worker and care transition services to older adults transitioning from medical care facilities back to their homes and communities.

The Coordinator works closely with hospitals, medical providers, community-based organizations, Michigan Hubs/Regional Health Collaboratives, and internal agency programs to establish effective referral and communication pathways, coordinate services, and strengthen transitions between health care and community-based systems.

The position supports successful implementation of the CTCS Operating Standard, achievement of grant performance outcomes, and the program's overall goal of helping older adults safely age in place while reducing avoidable high-acuity care utilization and hospital readmissions. The CTCS program specifically emphasizes proactive discharge planning, transition coaching, and post-discharge support.

Job Type: Full-time, Hybrid

Schedule:

• Monday through Friday, 8am to 4:30pm. Specific work schedule to be established with supervisor to ensure coverage for departmental or participant needs.
• Must live within the AAANM service area region.

Benefits:

• Health insurance
• Dental Insurance
• Vision Insurance
• Health savings account
• Life insurance
• Paid time off
• Tuition reimbursement
• 403(b) matching
• Flexible schedule

Essential Job Functions:

PROGRAM COORDINATION AND IMPLEMENTATION

• Coordinate the day-to-day implementation and operation of the CTCS Program in accordance with the CTCS Operating Standard.
• Develop, implement, and maintain program workflows, procedures, referral processes, and participant service pathways.
• Ensure participant intake, assessment, service planning, follow-up, and documentation activities are completed within required program timeframes.
• Coordinate participant referrals and assignment of CTCS cases to ensure timely engagement following referral or discharge.
• Monitor program activities for consistency with eligibility requirements, service standards, grant expectations, and agency policies.
• Identify operational barriers, service gaps, and opportunities for program improvement and work with agency leadership to develop appropriate solutions.
• Assist in developing and refining the CTCS service model as program requirements and community needs evolve.
• Serve as a primary resource for Care Transition Specialists regarding CTCS requirements, workflows, documentation, community resources, and participant service coordination.
• Promote consistent application of CTCS policies, procedures, and service standards across program staff.
• Facilitate communication between CTCS direct-service staff, leadership, Quality Management, Finance, and other agency departments involved in grant implementation.
• Attend organizational, team and other meetings as required or scheduled.
• Supports departmental and organizational efficiency, effectiveness, and impact to change for sustainability of the organization.
• Maintain HIPAA compliance and confidentiality at all times regarding participant and co-worker information per all agency guidelines.
• Continually seek and promote ways to improve process and procedures.
• Attend and participate in community meetings and workgroups as assigned by Supervisor.
• Ensure the responsibilities of the position are always handled in a safe and responsible manner.

Hospital and community partnerships

• Develop and maintain collaborative relationships with hospitals, medical care facilities, primary care providers, community-based organizations, social service agencies, and other organizations involved in care transitions.
• Collaborate with local hospitals to strengthen pre-discharge coordination and facilitate participant engagement prior to discharge whenever possible.
• Develop and maintain referral and communication pathways between medical providers, AAANM, and community-based services.
• Coordinate with Michigan Hubs/Regional Health Collaboratives and other Rural Health Transformation Program partners to address health-related social needs and strengthen cross-sector collaboration.
• Represent the CTCS Program at relevant community, health care, partner, and collaborative meetings.
• Promote awareness and understanding of CTCS eligibility, services, referral processes, and program objectives among community partners.

Program monitoring, quality and reporting

• Monitor program operations and participant outcomes to support compliance with CTCS and grant requirements.
• Ensure accurate, timely, and complete documentation of participant services and required outcome measures.
• Coordinate with Quality Management staff to collect, review, and monitor program data and performance metrics.
• Assist with preparation of required quarterly performance reports and other MDHHS reporting requirements.
• Monitor key CTCS outcomes, including:
• 30-day hospital readmissions and readmissions for the same diagnosis.
• Medication review and medication-management outcomes.
• Primary care follow-up within seven days.
• Long-term services and supports recommended, accepted, and received.
• Transportation to medical appointments.
• Durable medical equipment and accessible housing needs.
• Participant feedback and service-delivery improvement opportunities.
• Review program data to identify trends, barriers, gaps in service delivery, and opportunities for quality improvement.
• Collaborate with agency leadership and Quality Management staff on corrective actions and program improvement strategies as appropriate.

Care transition services

a. Maintain a participant caseload and provide direct CTCS services as program needs require.

b. Engage participants prior to discharge whenever possible and complete required post-discharge outreach and assessment.

c. Utilize person-centered planning to identify participant goals, needs, preferences, barriers, and supports necessary for a successful transition home.

d. Provide transition coaching, health education, social support, advocacy, and assistance navigating health and community service systems.

e. Offer and refer participants to home- and community-based services and long-term services and supports.

f. Assist participants with accessible housing, home safety, and durable medical equipment needs.

g. Coordinate transportation to primary care and other medical appointments, as appropriate.

h. Support medication management and facilitate medication review or consultation with an appropriate health care professional when indicated.

i. Facilitate primary care follow-up and support participants in completing follow-up with their primary care provider within seven days of discharge.

j. Educate participants regarding red-flag warning signs.

k. Conduct required ongoing post-discharge follow-up to assess service implementation, address barriers, and identify changing participant needs.

l. Advocate for participants and facilitate communication between participants, caregivers, health care providers, and community service organizations.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

· Bachelor's degree in human services or a related field preferred; equivalent combination of education and relevant experience may be considered.

· Experience in care coordination, community health, aging services, health care, social services, or a related field required.

· Community Health Worker credential/certification as required. If not credentialed at hire, ability to obtain required credentialing within an agency-established timeframe.

Knowledge, Skills and Abilities Required

· Knowledge of care transitions, community health, aging services, long-term services and supports, and community-based service systems.

· Strong program coordination and organization skills.

· Ability to interpret program requirements and translate them into practical procedures for direct-service staff.

· Ability to monitor program data, identify trends and concerns, and support quality improvement activities.

· Establish and maintain productive communication and working relationships with individuals inside/outside the Agency including consumers, guardians, management, community partners, coworkers and support staff.

· Represent the Agency’s set of core beliefs and values.

· Ability to effectively use telehealth technology to conduct participant interviews, as needed and per HIPPA guidelines.

· Effective written and verbal communication skills to convey and receive information (in person, via telehealth, on the phone, or through e-mail correspondence) and accurately document all forms of communication in appropriate locations.

· Attention to detail.

· Use of judgement, management, and ability to delegate and utilize appropriate resources in the organization for conflict management.

· Use critical thinking, problem solving and knowledge of agency to appropriate address complex situations.

· Ability to show and maintain empathy and compassion.

· Excellent listening skills and ability to decipher individuals’ needs and concerns.

· Maintain knowledge of and information about community resources.

· Good organizational, analytical, and judgment skills to manage time, prioritize, work independently, and handle multiple tasks.

· Proficiency in Microsoft Office Suite or similar software and standard office equipment including computers, calculators, and telephones

Certificates, Licenses, Registrations

· Community Health Worker Certification

· Maintain all required trainings and certifications.

· Possess a valid US driver's license and maintain auto insurance.

Equal Employment Opportunity Employer:
Area Agency on Aging of Northwest Michigan provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

Job Type: Full-time

Benefits:

• 403(b) matching
• Dental insurance
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Referral program
• Tuition reimbursement
• Vision insurance

Work Location: Hybrid remote in Traverse City, MI 49686