Transitional Care Manager

Prestera Center for Mental Health Services; Charleston (WV); On-site; USD 38,000 - 56,000; Full time

Job summary

Prestera Center for Mental Health Services in West Virginia seeks a Discharge Services Coordinator to coordinate discharge planning between hospitals, the agency, and families, ensuring smooth transitions and reducing avoidable readmissions.

The role involves screening, coordinating services, arranging transportation, and documenting in EHR systems, with a focus on community reintegration and continuity of care.

Qualifications

• Formal training in behavioral health, typically with a Bachelor's degree in Psychology, Social Work, Counseling, or Criminal Justice.
• Valid state driver's license required.
• Proficiency in Microsoft Word, Excel and PowerPoint.
• Experience with electronic clinical systems (EHR) and scheduling systems.
• Commitment to continuing education to maintain standards of care.

Responsibilities

• Screening and assessment to identify needs and goals at discharge.
• Coordinate services with families and treatment teams for successful transition.
• Attend treatment plan meetings and arrange transportation for individuals.
• Facilitate referrals to agency programs and maintain documentation.
• Provide education to individuals, families, and hospital staff on resources and rights.

Skills

Behavioral health training

Driver's license

Education

Bachelor's degree in Psychology/Social Work/Counseling/Criminal Justice

Tools

EHR systems

Scheduling systems

Microsoft Word

Microsoft Excel

Microsoft PowerPoint

Job description

Job PurposeCoordinates 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 DutiesScreening and AssessmentConducts 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 ServicesCollaborates 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 ServicesProvides 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.Primary AttributesProfessional & 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 MicrosoftPowerPoint. 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.