This role 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. The coordinator develops and maintains strong working relationships with medical and behavioral health hospital inpatient units, emergency departments, and community medical providers to enhance healthcare outcomes and connection to services. Key responsibilities include identifying clients admitted to and discharged from medical and behavioral health inpatient units, including DMHAS State Beds. For DMHAS State Beds, the role involves advocating for further testing/assessments, providing risk and treatment history, and identifying strengths and barriers to treatment and discharge. The coordinator facilitates communication between healthcare providers for scheduling follow-up appointments, medication reconciliation, arranging transportation, and other necessary services. Within the Behavioral Health Home (BHH) program, services include comprehensive care management, care coordination, health promotion, comprehensive transitional care, patient and family support, and referrals to community support services. The role also focuses on reducing healthcare disparities and advocating for clients' rights and access to services. Maintaining documentation in compliance with agency and program standards, and participating in staff meetings, supervision, and trainings are also required. Additional duties may be assigned.
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Job Type
Full-time
Career Level
Mid Level