Start the day excited to make a difference...end the day knowing you did. Come join our team.

Essential Functions & Responsibilities:

• Identifies and screens high-risk patients for care coordination.
• Coordinates care of patients with clinical partners; helps patients advance towards realistic and desirable outcomes.
• Organizes and expedites treatment plan of care activities.
• Assesses for long term and/or future patient care needs by identifying probable changes in level of independence or functional quality.
• Communicates activity status updates regarding treatment plan with clinical partners.
• Provides information and education on community resources to patient and their families.
• Identifies tentative discharge needs and develops a working discharge plan within the first 24 hours of admission.
• Develops, coordinates and communicates discharge plans with the patient, family members and care team and promotes communication and collaborative coordination of care amongst care providers.
• Documents assessment and overall discharge plan in medical record. Manages patient/family/physician expectations.
• Collaborates with leadership to appropriately address concerns related to delays in discharge, barriers to discharge and trends noted. Identifies financial barriers for a safe discharge and refers patients and families to appropriate agencies.
• Provides documentation in accordance with the hospital and developmental policies and procedures including, but not limited to, screening, initial discharge plan, weekly, status updates and whenever changes in the discharge plan occur.
• Assumes leadership role in facilitating meetings and comprehensive care planning with patient and interdisciplinary team.
• Ensures key regulatory requirements are met as defined by agencies, such as the Centers for Medicare and Medicaid, Virginia Health Quality Center, and the Joint Commission.
• Performs other duties as assigned.

Qualifications:

• Bachelor's degree in Human Services/Mental Health or other behavioral science discipline required; Master's degree preferred.
• CPR (AHA Healthcare Provider) required.
• CPI certification required within 90 days of hire.
• Certification or licensure in specialty preferred.
• Minimum of two years' experience in conducting assessments and evaluations required.
• Experience interacting with psychiatric and/or substance abuse patients in various stages of illness required.
• Experience with developmental issues across the life span, with in-depth knowledge of normal and abnormal development of children, adolescents, and adults required.
• Experience in utilization management, discharge planning or case management preferred.

As an EOE/AA employer, the organization will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status.