Works to provides high quality hospital transition care and coordination including medical, behavioral health and other community based services to designated participants with SPMI and/or chronic health conditions. Develops and maintains good working relationships with medical and behavioral health hospital inpatient units, emergency departments and community medical providers to improve healthcare outcomes and connection to services. Works to identify designated clients being admitted to and discharged from medical and behavioral health inpatient units including DMHAS State Beds. DMHAS State Beds Only: Collaborates by advocating for further testing/assessments to identify the appropriate levels of care, provides a history of risk and treatment to identify strengths and barriers to current treatment and discharge. Coordinates communication between medical and behavioral health care providers to provide proper scheduling of follow up appointments, medication reconciliation, arranging or providing client transportation, and other services as needed. BHH only: Provides BHH services including; Comprehensive care management Care Coordination Health promotion Comprehensive Transitional Care Patient and Family Support, Referral to Community Support Services. Works to help reduce health care disparities whenever possible. Advocates for clients’ rights and access to services. Maintains documentation in compliance with agency and program standards. Participates in staff meetings, supervision, trainings and other meetings as assigned. Additional duties as required.
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Job Type
Full-time
Career Level
Mid Level