Transitional Care Manager

Job Purpose

Coordinates discharge services with agency and hospital staff to ensure smooth transitions to appropriate care, support community reintegration, and reduce avoidable ER visits and hospital readmissions.

Primary Responsibilities and Duties

Screening and Assessment

• Conducts screenings and brief assessments with individuals to identify their needs and goals upon discharge.
• Utilizes the WVHIN to review existing assessment information to assist with discharge planning and transition.

Coordination of Services

• Collaborates with families and treatment teams to confirm services and supports are in place for successful transition upon discharge.
• Participates in all treatment plan meetings of assigned individuals.
• Arranges and/or provides transportation for individuals served.
• Facilitates referrals to agency programs.
• Prepares and maintains documentation within program guidelines.

Provision of Services

• Provides face to face contact within program guidelines.
• Provides education to individuals, families and hospital staff as needed to facilitate understanding of the individual’s needs, rights, and community resources.
• Encourages individuals to remain in a continuum of care to ensure success.

Qualifications: Primary Attributes

Professional & Technical Knowledge: Possesses the equivalent of formal training in behavioral health, usually in the form of a major in Psychology, Social Work, Counseling, or Criminal Justice as part of a Bachelor’s Degree program.

Continuing Education: Maintains current knowledge of standards of care and practices, typically acquired through continuing education.

Licenses & Certifications: A valid state-issued driver’s license is required.

Technical Skills: Prepares basic correspondence and simple reports in Microsoft Word. Uses Microsoft Excel to create tables and simple displays of information. Creates basic presentations in Microsoft PowerPoint. Demonstrates necessary proficiency with all electronic clinical systems, including EHR and scheduling systems, in use at the Company.

General Development: Displays basic organizational skills to self-prioritize and organizes own work. Determines effective responses to situations encountered within established precedent. Able to effectively communicate opinions drawn from conclusions using inference and logic. Exercises tact and diplomacy in the resolution of mild conflicts or disagreements.

Work Environment: Work is performed independently in the field, primarily in hospital settings working variable hours. Physical demands include frequent walking and standing. The position may occasionally involve lifting or carrying materials related to the individual’s care.