Health Homes Plus Transitions Coordinator

3 months ago

Troy, United States Trinity Health Full time
Employment Type:
Full timeShift:
Day Shift

Description:

We are looking for an energetic individual to join our Team

The ideal candidate will be someone who exercises compassion and dedication to serving the High-Need Seriously Mentally Ill population. The Health Home Plus (HH+) Transitions Coordinator is responsible for acting as a bridge between health care providers, social care providers and individuals in the community to promote health, reduce disparities and improve service delivery. Supporting individuals as they transition across the care continuum strengthens the connection with their providers and resources, which ultimately helps them to reach their potential. This includes the promotion of preventative care to reduce preventable emergency room and inpatient utilization, as well as an opportunity to address any social influencers of health.

Position Summary:
The HH+ Transitions Coordinator will develop a professional and trusting relationship with the High-Need Seriously Mentally Ill (SMI) population and community providers to ensure coordination and collaboration of services supporting positive outcomes. This is accomplished by providing community visits to patients discharged from the Inpatient Behavioral Health Unit or Crisis Unit at the Hospital and employing an empowerment approach in coordination with health and social care providers. This "bridge" from the hospital to the community ensures a warm handoff and allows for any barriers to be addressed in real time. The goal of the community based visit is to review the discharge instructions with the patient, repeat the "teach back" information protocol, identify any barriers to following the discharge plan (to include follow up appointments, prescriptions, transportation to appointments, etc.) and ensure that the patient has necessary follows up visits. Time is split between workingin the community conducting visits, working in the hospital and local shelter. This position will also support a small caseload of individuals enrolled in the program who are High-Need with Serious Mental Illness.

Education & Experience Requirements:
  • Bachelor's degree in Human Services** with minimum of two years' experience, or a Master's Degree in Human Services**, with one year experience, working with individuals diagnosed with Mental Illness, Substance Use Disorders, or Developmental Mental Disabilities providing direct linkage to community supports is required.
  • A Bachelor's degree in an unrelated field with at least five years of experience, working with clients with Mental Illness, Substance Use Disorders, or Developmental Disabilities.
  • Previous discharge planning, counseling, home care, and substance abuse treatment experience is desired.
  • Strong writing and communication skills are required, as well as knowledge of working with community agencies and managed care representatives.
  • Experience working with a diverse population and a strong understanding of multicultural issues is preferred.
  • A valid and insurable NYS Driver's License.
Job Requirements:
  • Extensive planning, organizational skills, and excellent communication with collateral contacts, referral and networking.
  • Ability to interview patients to assess decision making, coping skills, and barriers to managing their healthcare needs.
  • Adhere to policies and procedures as developed by the director of the department.
  • Be comfortable working with individuals actively experiencing behavioral health symptoms.
  • Must be able to work closely with others and work with members in both routine and stressful situations related to the their medical conditions and social influencers of health
  • Ability to work independently, setting priorities to coordinate care plan efficiently. As well as the ability to work in a team environment
  • Requires the ability to drive, must possess a valid driver's license.
  • Effective behavioral and educational strategies, including but not limited to, motivational interviewing, teach-back method and self-management support.
  • A working knowledge of entitlement programs (SSI, SSDI, Medicare, Medicaid, and Public Assistance) and community resources strongly preferred.
  • Strong Computer Literacy.
  • Prior experience with care management/coordination is preferred.


Pay Range: $22.55 - $32.30

Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location.

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.

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