HOSPITAL CARE COORDINATOR

Pawnee Mental Health; Manhattan (KS); On-site; USD 48,000 - 65,000; Full time

Job summary

Pawnee Mental Health seeks a dedicated care coordination professional to support clients admitted to inpatient psychiatric facilities. You will facilitate information flow, liaise with social workers, and participate in discharge planning to ensure smooth transitions.

Responsibilities include coordinating with outpatient and crisis teams, documenting care plans, and tracking admission status and follow-up needs.

Qualifications

• Bachelor’s degree in a human service field or equivalent work experience with one year substituting for one year of education.
• Strong oral and written communication skills using the English language.
• Basic personal computer skills that enable entry, retrieval, and use of electronic data.
• Ability to maintain client confidentiality and appropriately exchange protected information in accordance with agency policy and applicable law.
• Ability and willingness to travel routinely to state hospital facilities and, as needed, other inpatient facilities outside the Pawnee service area.
• Valid driver’s license and ability to meet agency requirements for driving on company business.

Responsibilities

• Serve as the primary liaison and care coordination contact for Pawnee clients admitted to inpatient psychiatric facilities, including state hospitals and private psychiatric hospitals.
• Facilitate timely, accurate information flow between Pawnee and inpatient facilities to support admission, treatment, discharge planning, and continuity of care.
• Maintain active communication with inpatient social workers, discharge planners, treatment teams, and other facility staff throughout the client’s admission.
• Conduct routine in-person visits to state hospital facilities for Pawnee clients and participate in treatment team or discharge planning meetings.
• Participate in inpatient treatment team and discharge planning meetings by sharing information and identifying community resources and gaps.
• Coordinate with Pawnee outpatient, crisis, community-based, medical, substance use, housing, peer support teams to develop a comprehensive transition plan before discharge.
• Communicate discharge plans to the appropriate Pawnee treatment team and schedule follow-up appointments, medication management, therapy, and community services.
• Assist with transition planning for clients returning to the Pawnee service area including transportation, housing, benefits, and follow-up appointments.
• Provide post-discharge contact to support linkage to services and identify barriers to follow-through.
• Ensure documentation is entered into the client record regarding admission, planning, discharge, and transition information.
• Track admitted clients and monitor status, discharge dates, and completion of transition activities.
• Identify trends in hospitalization and discharge barriers and communicate findings to leadership for system improvement.
• Collaborate with internal and external professionals on behalf of clients.
• Advocate for client needs while maintaining confidentiality and ethical standards.
• Attend and participate in program staffing, supervision, and coordination meetings.
• Meet administrative and clinical documentation requirements with accuracy and timeliness.
• Maintain knowledge of hospital care coordination, discharge planning, and transitions of care.
• Adhere to policies, code of conduct, confidentiality, and regulatory standards.
• Perform other duties as assigned.

Skills

Communication

English proficiency

Confidentiality

Travel readiness

Computer skills

Education

Bachelor's degree in human services

Tools

Microsoft Office

EMR/EHR

Telehealth platforms

Job description

Description

Who We Are

Pawnee Mental Health is proud of the high-quality services we offer and the positive outcomes our clients achieve. Our employees are the heart of our organization, and each person contributes to our mission. We’re looking for motivated, passionate individuals who want to use their skills to support others. We believe people facing mental health or substance use challenges deserve the chance to live meaningful, productive lives. If that mission resonates with you, we encourage you to explore this role and join us in making an impact.

What We Offer

At Pawnee Mental Health, we are committed to supporting our employees’ well-being by offering a comprehensive and competitive benefits package, including:

• HRSA- Health Workforce: Loan Repayment Program for Health Careers
• Continuing Education: Pawnee provides up to 5 days of additional paid leave for continuing education and a fund of up to $1,000 annually.
• Medical & Vision Insurance: Accessible plans to support your health needs offered through BCBS or Aetna.
• Dental Insurance: 100% covered by Pawnee for employees.
• Kansas Public Employee Retirement System (KPERS): Secure your future with KPERS retirement benefits, a lifetime pension program.
• Life Insurance: coverage up to 150% of your annual income and long-term disability insurance at no cost.
• Paid Holidays: Enjoy 8 paid holidays throughout the year.
• Generous PTO: Start earning 8 hours of PTO per month-equivalent to 12 days per year, with an increase to 24 days per year after your first anniversary.
• Paid Medical Leave: Receive a 40-hour bank of paid medical leave.
• Employee Assistance Program (EAP): Access support resources for your personal and professional life.
• Supplemental Benefits: Additional life insurance coverage, ambulance transportation, short term disability, critical illness, hospital indemnity, and more.

Responsibilities and Qualifications

Essential Responsibilities:

1. 1. Serve as the primary liaison and care coordination contact for Pawnee clients admitted to inpatient psychiatric facilities, including state hospitals, private psychiatric hospitals, and other inpatient behavioral health programs.
2. 2. Facilitate timely, accurate information flow between Pawnee Mental Health Services and inpatient facilities to support admission, treatment, discharge planning, and continuity of care, including ensuring relevant clinical and service information is available to the receiving or treating facility as permitted.
3. 3. Maintain active communication with inpatient social workers, discharge planners, treatment teams, and other facility staff throughout the client’s admission to identify treatment needs, anticipated barriers to discharge, and follow-up needs.
4. 4. Conduct routine in-person visits to state hospital facilities for Pawnee clients. Visits may include meeting with clients, participating in treatment team or master treatment plan meetings, coordinating with hospital social work staff, and reviewing progress toward discharge.
5. 5. Participate in inpatient treatment team and discharge planning meetings, as appropriate, by sharing relevant information from the client’s Pawnee treatment record, identifying available community resources, and identifying service gaps or barriers that may interfere with safe and successful community placement.
6. 6. Coordinate with Pawnee outpatient, crisis, community-based, medical, substance use, housing, peer support, and other service teams to develop a comprehensive transition plan before discharge.
7. 7. Prior to discharge, communicate the inpatient discharge plan to the appropriate Pawnee treatment team and facilitate scheduling of follow-up appointments, medication management, therapy, community services, crisis follow-up, and other recommended services.
8. 8. Assist with transition planning for clients returning to the Pawnee service area following inpatient hospitalization, including coordination of transportation, housing, medication access, benefits, outpatient appointments, safety planning, and other identified needs within the scope of the position.
9. 9. Provide or coordinate post-discharge contact for clients returning from inpatient psychiatric hospitalization or state hospital placement to support linkage to recommended services and identify emerging barriers to follow-through.
10. 10. Ensure appropriate documentation is entered into the client record regarding inpatient admission, facility contacts, treatment planning participation, discharge planning, scheduled follow-up, identified barriers, and relevant transition-of-care information.
11. 11. Track Pawnee clients admitted to inpatient psychiatric facilities and maintain an accurate process for monitoring admission status, expected discharge dates, follow-up needs, and completion of transition activities.
12. 12. Identify recurring trends in hospitalization, readmission, discharge barriers, and gaps in the community service delivery system; communicate findings to Crisis leadership and other appropriate agency leaders to support system improvement.
13. 13. Collaborate and consult with internal and external professionals on behalf of clients, including Pawnee therapists, case managers, community service staff, medical providers, crisis staff, hospital staff, jails, substance use treatment providers, managed care entities, and other community partners as appropriate.
14. 14. Advocate for client needs and appropriate community supports while maintaining professional boundaries, client choice, confidentiality, and applicable legal and ethical standards.
15. 15. Attend and actively participate in program staffing, clinical supervision, agency meetings, and cross-department coordination meetings as needed or requested.
16. 16. Meet administrative and clinical documentation requirements in terms of content, timeliness, accuracy, and professionalism.
17. 17. Maintain and advance knowledge and skills related to hospital care coordination, discharge planning, serious mental illness, crisis services, community resources, and transitions of care through training and ongoing professional development.
18. 18. Adhere to PMHS policies and procedures, the Pawnee Code of Conduct, confidentiality requirements, and applicable ethical codes and regulatory standards.
19. 19. Perform all other reasonably related duties assigned by immediate supervisor or other management personnel.

Requirements

Qualifications:

Required:

• Bachelor’s degree in a human service field or equivalent work experience, or a combination of work experience in the human services field and education with one year of experience substituting for one year of education required.
• Strong oral and written communication skills using the English language.
• Basic personal computer skills that enable entry, retrieval, and use of electronic data.
• Ability to maintain client confidentiality and appropriately exchange protected information in accordance with agency policy and applicable law.
• Ability and willingness to travel routinely to state hospital facilities and, as needed, other inpatient facilities outside the Pawnee service area.
• Valid driver’s license and ability to meet agency requirements for driving on company business.

Preferred:

• Experience working with adults who experience severe and persistent mental illness and/or with individuals receiving inpatient psychiatric treatment.
• Experience with case management, crisis services, discharge planning, hospital liaison work, or community behavioral health.
• Knowledge of community behavioral health resources and systems of care.
• Crisis training and familiarity with high-risk behavioral health populations.
• Experience with Microsoft Office Suite, Microsoft Outlook, electronic health records, and telehealth platforms commonly used by the agency.
• High attention to detail, strong organization, and ability to manage multiple active hospitalizations and time-sensitive discharge needs.

All employees will be required to submit to and pass a background check and drug screening.