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Patient Care Transition Specialist

2 months ago

Jacksonville, Florida, United States Mental Health Resource Center Full time
Job OverviewBenefits:
  • Comprehensive Dental Coverage
  • Health Insurance Options
  • Generous Paid Time Off
  • Vision Care Plans

Additional Perks
  • Medical, Dental, and Vision Insurance
  • Life Insurance Coverage
  • Disability Insurance
  • 403b Retirement Plan
  • Paid Time Off
  • Paid Holidays
  • Flexible Spending Accounts
  • Employee Assistance Programs
Company Overview
Mental Health Resource Center is a non-profit organization dedicated to delivering a broad spectrum of mental health and behavioral health services to the community. Our offerings include 24-hour emergency services, inpatient psychiatric care for individuals of all ages, and outpatient services such as medication management, case management, and counseling.

Position Summary
The Patient Care Transition Specialist within our Care Transitions program plays a vital role in assisting high-risk individuals who are not adequately connected to the necessary services and supports for a successful transition from higher levels of care to effective community-based care. This position primarily focuses on uninsured or underinsured individuals at high risk for excessive use of acute care services, including crisis stabilization, inpatient care, and detoxification services. The Specialist will evaluate individual needs, coordinate care plans, and conduct outreach to engage individuals referred from various facilities.

Key Responsibilities
  • Single Point of Accountability: Act as the primary entity responsible for coordinating services, supports, and cross-system collaboration to holistically meet individual needs.
  • Engagement: Establish trust and rapport with individuals by providing outreach and encouraging participation from their natural support systems.
  • Standardized Assessment: Utilize the LOCUS tool to determine the appropriate level of care.
  • Shared Decision-Making: Develop family and person-centered, individualized, strength-based care plans that prioritize the individual's values and preferences.
  • Community-Based Services: Ensure that services are delivered in inclusive, responsive, accessible, and least restrictive environments that foster community integration.
  • Coordination Across Health Care: Integrate services across physical health, behavioral health, social services, housing, education, and employment sectors.
  • Information Sharing: Use releases of information (ROIs) and data sharing agreements, in compliance with federal and state laws, to facilitate communication among involved service providers.
  • Effective Transitions and Warm Hand-Offs: Facilitate introductions between current providers and the care coordinator to ensure continuity of care.
  • Cultural and Linguistic Competence: Respect and build upon the values, preferences, beliefs, culture, and identity of individuals and their communities.
  • Outcome-Based: Align care plan goals with measurable success indicators, monitor progress, and adjust plans as necessary.
  • Stabilization of Mental Health Symptoms: Assist in the stabilization of mental health symptoms through effective care coordination.
  • Advocacy: Advocate for essential services and resources to implement care plans, making referrals to community services, and monitoring satisfaction and effectiveness.
  • Community-Based Outreach: Engage individuals referred from various facilities and provide information about available services.
  • Regular Contact: Maintain ongoing communication with individuals connected to services, including during appointments.
  • Outreach to Service Providers: Conduct outreach to service providers at critical points in the care system to inform them about available services.
Qualifications
  • Bachelor's degree in social work or a related human services field from an accredited institution is required.
  • Minimum of one year of experience in human services or a mental health-related field is necessary.
  • Proficiency in electronic health records and patient information systems must be demonstrated within three months of employment.
  • Strong skills in Microsoft Office, Outlook, and internet usage are required.
  • Must possess a valid driver's license and meet frequent driver requirements.
  • Excellent communication skills are essential for interacting with patients, families, caregivers, and other professionals.
Position Details
This is a Full-Time Days position.
Mental Health Resource Center is an Equal Opportunity Employer.