Discharge Coordinator (JTR)

Salt River Pima-Maricopa Indian Community•Scottsdale, AZ

5d•Hybrid

About The Position

Under direct supervision from the Journey to Recovery (JTR) Senior Nurse Manager, provides discharge coordination services to the patients of JTR Withdrawal Management (WM). Incumbent ensures that quality, effective and efficient services are provided to patients and that the patients are receiving services to meet their basic needs of becoming self-sufficient. Incumbent assists clinical staff in the implementation of specific treatment plans and coordinates with other service providers to organize an effective post-treatment strategy for patients to fully heal at home or at another facility. This job class is treated as FLSA Exempt and considered a DRIVING position.

Requirements

Bachelor’s degree in Counseling, Social Work, Psychology or closely related area and experience equivalent to three (3) years full-time in a social services field or with community outreach work.
In lieu of the bachelor's degree, candidates with an associate's degree in a related field and experience equivalent to five (5) years full-time professional level experience in social services, community outreach or a rehabilitation treatment setting will be acceptable.
Must have current certification in First Aid and CPR prior to working with patients.
Must possess a CPR/Basic Life Support (BLS) certification.
Must possess and maintain a Valid Arizona Driver’s License.

Nice To Haves

Knowledge of the culture, customs, traditions, history and government of the Salt River Pima- Maricopa Indian Community.
Knowledge of the needs of families within the SRPMIC.
Knowledge of policies, procedures, rules and guidelines (State and Tribal) for related HHS programs, including procedures on confidentiality of case files.
Knowledge of such programs as, but not limited to: tribal mental health ordinance, involuntary commitment, AHCCCS, and Title IXX.
Knowledge of discharge planning and community resources.
Knowledge, at a working level, of the uses and side effects of psychotropic medications.
Knowledge (basic) understanding of behavioral problems, serious, often chronic, mental illness, substance abuse, and unique needs of each.
Skill in assessing client needs and identifying resources/services available to meet needs.
Skill in interviewing clients under stressful situations.
Skill in establishing and maintaining effective working relationships with the clients, SRPMIC staff, and representatives of resource agencies.
Skill in using the personal computer and related software, in order to fulfill job requirements.
Ability to communicate effectively, both orally and in writing.
Ability to establish and maintain accurate record keeping systems and procedures, including computerized record keeping.
Ability to work evenings, weekends and to travel in state, as needed.
Ability to work as part of a multidisciplinary team and to facilitate close working relations and cooperation with community resources.
Ability to use initiative and independent judgement and when to collaborate with appropriate members of the discharge planning team.
Ability to drive various SRPMIC vehicle(s).
Ability to work with a variety of staff members in a team approach to service delivery.
Ability to operate a variety of standard office equipment including photocopiers, FAX machines, typewriters and personal computers.

Responsibilities

Meet with patients and discuss plans with assigned therapist(s) to assist with discharge planning.
Works with medical/RN team and collaborates with Medical Provider to determine appropriate level of care in discharge plan.
Develops a tailored discharge plan and documents all the necessary information in patients' records and begins this at admission.
Coordinates care management services with respective clinical staff to ensure a smooth transition of care with application of appropriate community resources.
Confers with representatives from public and private agencies and organizations such as, but not limited to, Social Security, State/Tribal Welfare Offices, AHCCCS, Legal Aide/Services, Psychiatric hospitals, Behavioral Health Agencies, Department of Corrections, Primary Care Providers and Residential Treatment Facilities to assist clients in applying for and obtaining appropriate needed services.
Ensures clients' compliance through documentation of participation and progress on discharge.
Assists with client support services, such as arrangements for transportation to ensure patients arrive safely to next transition of care.
Final documentation of discharge plan is placed in the patient medical record within two (2) working days of discharge or transfer.
Prepares reports, case histories and case studies to aide in the compliance of regulatory entities.
Maintains accurate database for easy retrieval and reference purposes.
Prepares periodic reports from records, as required.
Ensures accurate record keeping, using computerized database.
Establishes and maintains patient records in accordance with program policy and procedures and follows all HIPPA requirements.
Participate in case staffing or staff meetings to ensure a multidisciplinary approach to a tailored discharge plan for each patient.
Discuss issues or cases that require additional input and planning.
Provides updates on the status of clients in outside psychiatric facilities and/or residential treatment to clinical staff as needed.
Update status of JTR census to reflect the patient movement.
Provides patient and support person(s) with referrals to community resources as needed.
Administers the patient satisfaction survey prior to discharge.
Performs other duties as assigned to maintain and enhance program and agency operation.