Transitional Care Manager

Prestera Health Services•Charleston, WV

1d•Onsite

About The Position

The Transitional Care Manager coordinates discharge services with agency and hospital staff to support smooth transitions to appropriate care, community reintegration, and reduced avoidable emergency room visits and hospital readmissions. The role works independently in the field, primarily in hospital settings, and may require variable hours. The manager screens and briefly assesses individuals to identify needs and goals upon discharge, uses WVHIN to review existing assessment information, and coordinates with families and treatment teams to ensure services and supports are arranged. The role also participates in treatment plan meetings, arranges or provides transportation, facilitates referrals, maintains program documentation, provides face-to-face contact, and educates individuals, families, and hospital staff about needs, rights, and community resources. The manager encourages individuals to remain engaged in a continuum of care.

Requirements

Equivalent of formal training in behavioral health, usually a major in Psychology, Social Work, Counseling, or Criminal Justice as part of a bachelor’s degree program.
Maintain current knowledge of standards of care and practices, typically through continuing education.
Valid state-issued driver’s license.
Prepare basic correspondence and simple reports using Microsoft Word.
Use Microsoft Excel to create tables and simple displays of information.
Create basic presentations using Microsoft PowerPoint.
Demonstrate necessary proficiency with the company’s electronic clinical systems, including EHR and scheduling systems.
Demonstrate basic organizational skills to self-prioritize and organize work.
Determine effective responses to situations within established precedent.
Communicate opinions drawn from conclusions using inference and logic.
Exercise tact and diplomacy in resolving mild conflicts or disagreements.

Responsibilities

Conduct screenings and brief assessments to identify individuals’ needs and goals upon discharge.
Use WVHIN to review existing assessment information to assist with discharge planning and transition.
Collaborate with families and treatment teams to confirm services and supports are in place for a successful transition.
Participate in treatment plan meetings for assigned individuals.
Arrange and/or provide transportation for individuals served.
Facilitate referrals to agency programs.
Prepare and maintain documentation within program guidelines.
Provide face-to-face contact within program guidelines.
Educate individuals, families, and hospital staff as needed about the individual’s needs, rights, and community resources.
Encourage individuals to remain in a continuum of care to support success.