Post Hospital Liaison; Integrated Care;330
About The Position
The Post Hospital Liaison works with internal and external community partners to support clients following psychiatric hospitalization, helping them achieve stability and recovery through connections to services that address social drivers of health. The liaison assists behavioral health staff and clients with accessing services and assistance, and identifies and reaches out to clients who presented at a hospital emergency department or were admitted as inpatients. The role helps reduce hospital readmissions and increase use of Access to Wellness funds. The liaison responds to information and referral inquiries, builds relationships with hospital behavioral health and emergency department staff, advocates for clients, coordinates applications and referrals, assesses client needs and eligibility, and maintains records in the EHR and other systems. The role includes daily outreach to clients after hospitalization, coordination of follow-up services within seven days of discharge, support for high utilizers, and post-hospitalization billable services when appropriate. Office-based case management and counseling may also be provided as needed. The position operates in a professional office environment and routinely uses standard office equipment. Travel and work outside normal hours may be required for meetings, presentations, training, and other events.
Requirements
- Bachelor’s degree in social work.
- Ohio Social Work License.
- Experience working with clients with SPMI.
- Competence using varied technology systems.
- Experience accurately assessing and responding to people with varied needs and crisis levels.
- Excellent communication skills and grammar.
- Valid driver’s license in the State of Ohio.
- Ability to understand and accept a systems approach to service delivery and the agency’s and program’s philosophy and goals.
- Ability to work closely and collaboratively with team members and social support organizations and agencies.
- Ability to balance multiple priorities and manage time effectively.
- Ability to communicate clearly and effectively in writing and verbally.
- Ability to interact appropriately, respectfully, understandingly, and patiently with people of diverse backgrounds, physical capabilities, emotional states, and skill levels.
Nice To Haves
- Conversational Spanish ability to serve Spanish-only-speaking clients.
Responsibilities
- Provide quality customer service in response to information and referral inquiries from individuals, professionals, and organizational clients.
- Establish positive relationships with behavioral health and emergency department staff at local hospitals.
- Advocate for contacts and clients who cannot independently access resources or who meet program eligibility criteria.
- Collaborate with Centers staff and partner agencies to help clients submit and complete applications and provide required documents.
- Respond to applicant referrals by completing intake information and assessing client needs, preferences, and eligibility.
- Record assessment and screening tools in the EHR and other required systems.
- Maintain current client data, detailed case notes, client files, and program information in the client database.
- Communicate regularly with clients, service coordinators, service providers, and support personnel to ensure program requirements and resources are distributed accurately.
- Manage the notify and ADT panels daily and conduct post-hospitalization outreach to connect clients with follow-up services.
- Collaborate with Centers staff to ensure clients receive services within seven days of hospital discharge.
- Identify high utilizers and work with the care team to reduce dependence on hospital systems.
- Provide billable services to Centers clients after hospitalization when appropriate.
- Provide office-based case management and counseling services as needed.
- Attend training and workshops related to program improvement and professional development.
- Perform other duties as assigned.
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What This Job Offers
Job Type
Full-time
