Transitional Care Manager (78466)
Posted
Job Purpose
Coordinates discharge services with agency and hospital staff to ensure smooth transitions to appropriate care, support community reintegration, and reduce avoidable ER visits and hospital readmissions.
Primary Responsibilities and Duties
- Screening and Assessment
- Conducts screenings and brief assessments with individuals to identify their needs and goals upon discharge.
- Utilizes the WVHIN to review existing assessment information to assist with discharge planning and transition.
- Coordination of Services
- Collaborates with families and treatment teams to confirm services and supports are in place for successful transition upon discharge.
- Participates in all treatment plan meetings of assigned individuals.
- Arranges and/or provides transportation for individuals served.
- Facilitates referrals to agency programs.
- Prepares and maintains documentation within program guidelines.
- Provision of Services
- Provides face to face contact within program guidelines.
- Provides education to individuals, families and hospital staff as needed to facilitate understanding of the individual’s needs, rights, and community resources.
- Encourages individuals to remain in a continuum of care to ensure success.