Care Transitions Coordinator

Employment Type:

Shift:

Description:

Serves as a professional working in the behavioral health department. Is responsible for providing coordination of care to assist patient and their support systems as they move through levels of care. Services include the assessment and management of barriers for discharge, collaborating with other members of the health care team or community-based services to improve client access and options of services and assists patients in the process of navigating post inpatient care.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

• Maintains good rapport and cooperative relationships. Approaches conflict in a constructive manner. Helps to identify problems, offer solutions, and participate in their resolution.
• Provide appropriate & timely discharge planning from hospital, arrange follow- up care and face-to-face interaction with the patient and patient's support to ensure follow through with care transitions.
• Maintains the confidentiality of information acquired pertaining to patient, physicians, colleagues, and visitors to Trinity Health. Discusses patient and hospital information only among appropriate personnel in appropriately private places.
• Behaves in accordance with the Code of Conduct, Service Excellence Standards, and the Mission, Vision, Values, and policies of Trinity Health.
• Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of coworkers, and to report all preventable hazards and unsafe practices immediately to management.
• Promote adherence to post inpatient care plans.
• Monitors execution of transition plan through timely follow-up
• Supports a recovery-focused environment and patient-centered treatment approach.
• Provides patients with self-management skills and educational information so they can be full participants in their own treatment and recovery.
• Assures complete, accurate, and timely documentation of clinical information in the EHR, incorporating current documentation and requirements.
• Assures the consistent delivery of appropriate evidence-based services to achieve measurable improvements in quality of care.
• Provides behavioral health education and utilizes community resource opportunities for the individual and/or family.
• Monitors and coordinates the delivery of health services including linking with other treatment providers and community services as appropriate.
• Maintains a process for systematic follow-up by determining the effectiveness of the treatment plan with documentation of patient care outcomes.
• Provides timely feedback to the Providers and other treatment team members regarding patients' care, treatment recommendations, and progress through verbal communication, EHR documentation, systematic comprehensive case review, record review, and informal discussions.
• Engages in regular communication with patient after discharge to jointly assess, prioritize, and respond to patients' care needs.

OTHER FUNCTIONS AND RESPONSIBILITIES

Performs other duties as assigned.

REQUIRED EDUCATION, EXPERIENCE AND CERTIFICATION/LICENSURE

Education:   Bachelor’s degree in social work or other human service related field

Experience:  1+ year(s) in behavioral health/collaborative care preferred.

Certification/Licensure -None required of position.

REQUIRED SKILLS AND ABILITIES

1.       Knowledge of care transitions/Zero Suicide model preferred.

2.       Experience in working with patients who have behavioral health conditions.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.