Care Transition Coordinator

Mental Health Resource Center•Jacksonville, FL

About The Position

The Care Coordinator with our Care Transitions program assists high-risk individuals who are not effectively connected with the services and supports they need to transition successfully from higher levels of care to effective community-based care. This role focuses on uninsured or underinsured individuals who demonstrate high risk for high utilization of acute care services, such as crisis stabilization, inpatient care, and detoxification services. The Care Coordinator will assess individual’s needs, coordinate a plan of care and/or treatment plan, and conduct outreach to engage individuals referred from inpatient psychiatric facilities, jail, or other community providers.

Requirements

In order to be considered, candidates must have a Bachelor’s degree in social work or a related human services field from an accredited university or college (a related Human Services field is defined as one in which 30 hours of coursework includes the study of human behavior and development) required.
One year of experience working in human services or a mental health-related field is required.
Proficiency in the RBHS/MHRC Electronic Health Records (EHR) and Patient Information System demonstrated within three months of employment.
Proficiency in Microsoft Office, Outlook, and use of the Internet required.
Must meet Frequent Drivers requirements, including a valid Florida driver’s license, and insurance coverage equal to or exceeding 50,000/100,000/50,000 split limits.
Strong communication skills are essential and this individual must be able to interact appropriately with internal and external customers, including patients, families, caregivers, community service providers, supervisory staff, and other department professionals.

Responsibilities

Single Point of Accountability: Serves as the single entity responsible for the coordination of services, supports, and cross-system collaboration to ensure holistic meeting of the individual’s needs.
Engagement: Builds trust and rapport with individuals by going to them and encouraging the full participation of their natural supports. The care plan will include activities and interventions that utilize these natural support sources.
Standardized Assessment: Uses the LOCUS to determine the appropriate level of care.
Shared Decision-Making: Creates family and person-centered, individualized, strength-based plans of care. The individual's values and preferences are prioritized, with the care coordinator providing options and choices.
Community-Based Services: Ensures that services and supports are provided in inclusive, responsive, accessible, and least restrictive settings that promote community integration.
Coordination Across Health Care: Integrates services across physical health, behavioral health, social services, housing, education, and employment.
Information Sharing: Utilizes releases of information (ROIs) and data sharing agreements, compliant with federal and state laws, to share information among Network Service Providers, natural supports, and system partners involved in the individual’s care.
Effective Transitions and Warm Hand-Offs: Facilitates face-to-face introductions between current providers and the care coordinator. The “warm hand‐off” is both to establish an initial face‐to‐face contact between the individual and the care coordinator and to confer the trust and rapport the individual has developed with the provider to the care coordinator.
Cultural and Linguistic Competence: Demonstrates respect for and builds on the values, preferences, beliefs, culture, and identity of the individual and their community.
Outcome-Based: Ensures care plan goals and strategies are tied to measurable indicators of success, monitors progress, and revises plans as needed.
Stabilization of Mental Health Symptoms: Facilitates stabilization through care coordination, assessment, and outreach.
Advocacy: Advocates for necessary services and resources to implement the care plan or treatment plan, making referrals to community services, coordinating service delivery, and monitoring satisfaction and effectiveness.
Community-Based Outreach: Provides outreach to individuals referred from inpatient psychiatric facilities, jails, etc., and engages them with information about CSC services.
Regular Contact: Maintains regular contact with individuals once they are connected to CSC services, including during psychiatric medical service appointments and as needed to coordinate services.
Outreach to Service Providers: Provides community-based outreach to service providers at crisis points in the system of care to inform them about CSC services.