Regional Transition Care Manager, North Florida - (Tallahassee, FL)

Works in collaboration with a member's primary care manager (CM) to ensure safe and appropriate transitions between levels of care, including working as a part of the interdisciplinary care team in the development and execution of a person-centered transition plan. Coordinates all support staff, (e.g., Housing Outreach Specialist, DME Specialist, Community Advocate) and services required for a safe transition. Along with the primary CM, collaborates with family/caregivers to identify and ensure caregiver needs are met and services are in place to support a successful return to the community. Establishes and maintains best practices reflecting regional variations affecting successful transitions and HCBS capacity, including establishing relationships with key facilities, providers, and home and community based (HCBS) resources to assist in transitions. Assists with identifying resources with specialized capabilities when members with complex needs transition to the community.