Transitions Coordinator, Integrated Care Department - Get a FREE Master’s degree in Clinical Mental Health Counseling! - Center for Life Management

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Center for Life Management (CLM) provides the area's most comprehensive array of outpatient mental health services for Southern New Hampshire. Our Integrated Care Program is a highly innovative approach to whole healthcare that encompasses the integration of treatment modalities for mental and physical health needs. The Integrated Care (IC) team utilizes a full wrap-around care model that is necessary to support individuals with addressing the intersection of their complex mental and chronic physical health conditions. The IC Transitions Coordinator collaborates, communicates, coordinates and ensures individuals who are admitted to and discharged from an inpatient medical facility has rapid access to the IC team, ongoing outpatient treatment from the IC team, and follow-up scheduled with their medical providers (primary care, specialty care and psychiatric, as needed). Coordinates on going communication with providers outside CLM by coordinating open doors, facilitating documentation exchange.  Additionally, the Transitions Coordinator ensures efficient and financially-sound workflows which enable all clinical staff to provide timely, thorough and complete service delivery. This is a part time, 25 hour a week position. The schedule is Monday – Friday 8:30 am - 2 pm.

Major Functional Areas and Description of Duties

• Implement and sustain partnerships with inpatient and outpatient medical facilities throughout New England to improve communication and care coordination of any and all client admissions and discharges by:

• Developing strong, professional relationships with hospital social workers and ancillary staff to coordinate and transition client’s care to CLM upon discharge;
• Ensuring releases of information are obtained, contact information for social workers and medical providers is relayed and open communication is maintained between all parties to collaborate on client care;
• Educating on Integrated Care Referral requirements and synchronizing access to ongoing Integrated Care treatment at CLM.

• Liaise and triage all after care appointments by: 

• Scheduling primary care appointments within 48 hours of hospital discharge (new and active clients);
• Arranging medication management appointments via centralized scheduling (active clients) and therapy/nursing/FSS appointments via coordination with IC team;
• Collaborating with Quality Improvement Analyst to organize team meetings, multi-disciplinary team meetings and open doors to discuss provisions for discharge planning;
• Working in partnership with Emergency Rooms to discuss discharge plan following assessment and provide updates to team members;
• Assisting staff in locating client whereabouts in regards to inpatient, emergent psychiatric and/or medical care admissions by outreaching Emergency Departments and Residential Substance Use Disorder Programs when contact is lost with client;
• Obtaining discharge summaries for medical admissions that are related to psychiatric needs;
• Collaborating with Partial Hospitalization Programs such as Elliot, Southern NH Medical Center, Hampstead Hospital and Parkland Medical Center to ensure that clients have follow-up care following completion of their program;
• Obtaining progress notes and discharge paperwork in a timely manner to ensure CLM team is fully aware of care plan needs;
• Providing confirmation letter for all hospital discharge clients to social worker outlining CLM services and all upcoming CLM appointments;
• Monitoring receipt of signed forms confirming client consent to schedule appointments;
• Collective Medical/Closed loop referral.

• Coordinates Intakes – Process department referrals. Verifies insurances and obtains authorizations. Prepares intake packets and supporting documentation from ancillary providers. Completes pre-admit/intake process, including, but not limited to, entering demographics into electronic health record, opens episode of care, pre-screening, and scheduling. Supports integration/inputting of current patient registry and other tracking tool information into electronic health record.
• Manages Patient Registry and Caseloads – Utilizes available data to monitor active versus inactive clients, wait list and timely provision of care. Maintains up-to-date patient registry. Prepares, distributes, collects and tracks all outpatient scales, annual packets, returned and outstanding documentation to ensure client’s records are in full compliance. Track outcomes post discharge and processes closing forms.
• Collect, process, and report on data related to hospitalization admissions and discharges by maintaining a current roster/tracker;
• Collaborate with all team members, CLM’s New Hampshire Hospital Liaison, CLM’s Integrated Care team, and other external partners to include parents/guardians, natural supports, police, emergency medical staff, social workers and medical staff at hospitals to ensure a wrap-around approach is provided for discharge and continuity of client care;
• Serve on appropriate committees, both internally and externally, as determined by supervisor;
• Function professionally and in a manner that protects the integrity, confidentiality and rights of all clients and staff;
• Execute all responsibilities and timely documentation in accordance with agency policies and federal/state standards;
• Represent CLM in a professional and appropriate manner in all settings;
• Perform all other duties as assigned by supervisor.

Qualifications and Skills

• High school diploma or equivalent required; Associate’s or Bachelor’s degree preferred.
• Minimum of five years of experience in a high-volume medical office and/or emergency service environment required;
• Strong communication, interpersonal, and customer service skills required to interact with clients, families, staff and visitors in a professional manner;
• Ability to work in a fast-paced environment with strong organizational skills, ability to problem solve, multi-task, and manage competing tasks while attending to details and adhering to deadlines;
• Ability to maintain composure and exercise sound judgment in routine, urgent, and emergent situations and tasks;
• Proficient computer skills and knowledge of Microsoft office applications with emphasis on Word, Excel, Outlook and TEAMS;
• Ability and desire to work as part of a team while also able to be self-directed and motivated with minimal supervision;
• Flexibility to adapt schedule and fill in as needed;
• Ability to acquire and effectively execute new skills as needed according to evolving department needs.

Physical Demands and Working Conditions

The majority of the work takes place in an office setting with occasional remote work. Manual dexterity is needed to use computers and standard office equipment. The ability to sit for extended periods of time is required. Reliable internet for remote work is required.

Benefits

At Center for Life Management, we offer a robust benefits package because caring for our staff is just as important as caring for our clients. Part Time benefits include:

• Paid holidays (8) with bonus birthday holiday in your birth month
• Employee Assistance Program (EAP), accessible to staff and their natural supports
• Company issued cell phone and laptop as needed for role
• Scholarship for professional advancement
• Mileage reimbursement for applicable positions
• On the job training and continuing education opportunities
• Rewarding and supportive work environment with excellent opportunities for career growth
• Meaningful relationships with your co-workers and the individuals we serve
• Flexible work schedule
• Teamwork, teamwork and more teamwork!

The Center for Life Management has partnered with New England College to offer a Master’s Degree! This is an exciting opportunity for CLM staff to earn a Master of Science in Clinical Mental Health Counseling (MS) degree in 3 years. 

Who’s Eligible and What’s Required:

• Must be a regular, full-time CLM employee in good standing for 9 months or more.
• Must hold a Bachelor’s Degree.
• Must agree to a five (5) year commitment of full-time employment in good standing with the Center for Life Management (beginning from start date/year of Professional Development Program participation).
• Participants must maintain a B average to continue participation in the program.

*Cost of tuition is covered by Center for Life Management

*Employee is responsible for applicable taxable portion of tuition remission

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