Post Hospital Liaison; Integrated Care;330

The Centers • Cleveland, OH

42d • Hybrid

About The Position

This position will work closely with internal and external community partners to support clients who have experienced a psychiatric hospitalization with achieving stability and recovery support through linkage to services to overcome social drivers of health. The Post Hospital Liaison will assist behavioral staff and clients with applying for unique, but vital services and assistance in their journey of recovery. The primary role will be to identify & outreach clients who have had a hospital presentation in the emergency department or inpatient. This position will be key in reducing the readmission rate of clients and increasing the utilization of Access to Wellness funds.

Requirements

• Bachelor’s degree in social work
• Ohio Social Work License
• Experience working with clients with SPMI
• Must demonstrate competent technology skills in use of varied technology systems.
• Experienced in accurately assessing and responding to people of varied needs and crisis levels.
• Excellent communication skills and grammar.
• Must have a valid driver’s license in the State of Ohio.
• Must understand and accept a systems approach to service delivery, agency and program philosophy and goals.
• Must be able to work closely and collaborate with other team members and social support organizations/agencies.

Nice To Haves

• Bi-lingual with the ability to speak conversational Spanish to Spanish only speaking clients

Responsibilities

• Provide outstanding quality customer service in responding to inquiries for information and referral from individuals, professionals, and organizational clients.
• Establish positive relationships with behavioral health and Emergency Department staff at local hospitals.
• Persistently and firmly advocate for contacts/clients who otherwise are unable to independently access resources or who meet program eligibility criteria.
• Collaborate with Centers staff and partner agencies to assist clients in submitting, completing, applications and providing necessary documents.
• Respond to referrals of applicants including completing intake information, assessment of the client’s needs, preferences, and eligibility.
• Record necessary assessment and screening tools in the EHR and other necessary systems.
• Maintain current client data, keep detailed case notes, client files and program information up to date and organized in client database.
• Communicate regularly and effectively with the client, service coordinators, service providers, and support personnel to ensure that program requirements and resources are distributed accurately.
• Manage the notify and ADT panels daily to outreach clients post hospitalization to ensure connection to follow up services.
• Collaborate with Centers staff to ensure clients receive services within seven days of discharge from a hospital event.
• Identify high utilizers and work with the care team to reduce dependence on hospital systems.
• Provide billable services to Centers clients post hospitalization when appropriate.
• Provide office-based case management and counseling services as needed.
• Attend training and workshops related to program improvement and professional development.
• Other duties as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level