Transitional Care Manager (78514)

Prestera Health Services; Charleston (WV); On-site; USD 25,000 - 36,000; Full time

Job summary

Prestera Health Services in Charleston, WV seeks a discharge services coordinator to work with hospital staff to ensure smooth transitions, support community reintegration, and reduce avoidable ER visits.

The role involves conducting screenings, coordinating services, arranging transportation, and educating patients and families, with strong emphasis on documentation using EHR and scheduling systems.

Qualifications

• Equivalent of formal training in behavioral health, usually in Psychology, Social Work, Counseling, or Criminal Justice as part of a Bachelor’s Degree program.
• Maintains current knowledge of standards of care through continuing education.
• A valid state-issued driver’s license is required.

Responsibilities

• Screenings and brief assessments to identify needs and goals upon discharge.
• Review assessment information using WVHIN to assist discharge planning.
• Collaborates with families and treatment teams to confirm needed services.
• Attends treatment plan meetings for assigned individuals.
• Arranges and/or provides transportation for individuals served.
• Facilitates referrals to agency programs.
• Maintains documentation within program guidelines.
• Provides face-to-face contact with individuals and families.
• Educates individuals, families and hospital staff on needs, rights, and resources.
• Encourages a continuum of care to support ongoing success.

Skills

Discharge planning

Communication

Documentation

Education

Bachelor's degree in Psychology

Bachelor's degree in Social Work

Bachelor's degree in Counseling

Bachelor's degree in Criminal Justice

Tools

Microsoft Word

Microsoft Excel

PowerPoint

EHR systems

Scheduling systems

Job description

Job Details: Job Location: Morris Street - Charleston, WV 25301, Salary Range: $21.97 Hourly,

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 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.