Hospital Discharge Social Work Jobs (NOW HIRING)

Job Number: 119

Location: Midland

Supervises: N

FLSA: Non-Exempt

Division: MH

Salary: $20.65 per hour. Sign on bonus may be available.

Shift: M-F 8am - 5pm; Assigned work hoursmay change as the needs of the agency and clients change

Driving required: Y

Travel required: Y

Settings: office, field

POSITION SUMMARY/JOB PURPOSE:

The Hospital Discharge Coordinator works closely within the Permian Basin Behavioral Health Center helping individuals identify and access resources to utilize once they have been released from the inpatient psychiatric hospital. The Hospital Coordinator provides support in the discharge planning process for individuals from the first day they are admitted to inpatient treatment, follows them throughout treatment, and assists them in establishing a safe discharge plan once they return to the community. The Hospital Coordinator will work closely with PermiaCare crisis teams in providing crisis follow up and monitoring.

This position works independently, under limitedsupervision, reporting major activities through periodic meetings.

EDUCATION, EXPERIENCE, OTHER QUALIFICATIONS:

Education Required: A Bachelor's degreefrom an accredited college or university with a major in psychology, social work,medicine, nursing, rehabilitation, counseling, sociology, human growth anddevelopment, physician assistance, gerontology, special education, educationalpsychology, early childhood education or early childhood intervention or abachelor's degree with at least 30 hours of coursework in the previous fields.

Experience Required: At least 1 yearexperience working with individuals struggling with mental health, substanceuse, involved in the criminal justice system, or working with individual duringacute crisis needing psychiatric hospitalization preferred.

Registration, Certification, Licensure or otherQualifications Required:

• Must maintain a valid Texas Driver's license, auto liability insurance and a driving record acceptable to PermiaCare's insurance requirements.
• Required to pass criminal history and background checks as well as pre-employment drug screen.
• Must obtain QMHP certification within 6 months.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Initiate discharge planning upon admission and continuously update the plan throughout the patient's hospitalization.
• Complete discharge assessments to identify patient needs, barriers to discharge, community support requirements.
• Collaborate with psychiatrists, nursing staff, therapists, case managers, utilization review, and other members of the treatment team to develop individualized discharge plans.
• Coordinate referrals and appointments for outpatient mental health treatment, medication management, therapy, substance use treatment, and community resources.
• Arrange placement in appropriate levels of care including outpatient services, intensive outpatient programs, partial hospitalization programs, residential treatment, crisis stabilization units, nursing facilities, shelters, or assisted living facilities as needed.
• Communicate and collaborate with family members, caregivers, legal guardians, and support systems, while adhering to confidentiality and release of information requirements.
• Complete collateral contacts to assess discharge environments and assist with safety planning and securing the home environment when indicated.
• Facilitate discharge meetings with patients and families to review treatment recommendations, medications, follow-up appointments, and safety plans.
• Ensure all discharge documentation, aftercare plans, and referrals are completed accurately and within required timeframes.
• Coordinate transportation arrangements and assist with addressing barriers such as housing instability, financial concerns, lack of transportation, or limited support systems.
• Verify insurance benefits, authorizations, and payer requirements related to discharge services and aftercare needs when applicable.
• Maintain knowledge of community resources, local mental health providers, substance use treatment programs, social services, and support agencies.
• Monitor and track discharge outcomes, follow-up compliance, and readmission trends to improve continuity of care and patient outcomes.
• Participate in interdisciplinary treatment team meetings and provide updates regarding discharge progress and barriers.
• Ensure discharge plans comply with hospital policies, regulatory requirements, accreditation standards, and state and federal regulations.
• Provide patient and family education regarding diagnoses, medications, coping skills, crisis resources, and available community supports.
• Assist patients in obtaining prescriptions, durable medical equipment, financial assistance, and other resources necessary for a successful transition to the community.
• Advocate for patient needs and facilitate access to services that support recovery and community integration
• Provide holistic care across the health spectrum by addressing all needs identified by client.
• Encourage and/or include participation of family members and others important to the client, subject to privacy and confidentiality requirements and client's consent.
• Develop recovery plans that are comprehensive, person-centered, and family-centered in agreement with and endorsed by the client.
• All follow up documentation and progress notes should be person-centered and completed within required timeframes.
• Meet unit performance measures or targets.
• Enter accurate and appropriate documentation of services within timeframe required.
• Maintain confidentiality of sensitive records and treatment information, client files and protected health information in compliance with HIPAA, laws, rules and regulations, and established procedures.
• Maintain regular and reliable physical on-site attendance. Regular attendance, dependability, and promptness are required for the scheduled work day 100% of the time, to ensure consistency and completeness of program's processes.
• Comply with the Abuse, Neglect, and Exploitation policy and reporting requirements.
• Adhere to the Code of Conduct and Standards of Behavior policy requirements.
• Establish and maintain effective work relationships with individuals served and their families, supervisors, co-workers and visitors by demonstrating cooperative, courteous and respectful behavior at all times.
• Communicate regularly with supervisor.
• Open and process mail/email in a timely manner.
• Answer phone, collect phone messages and respond to requests timely and accurately.
• Maintain safe and clean working environment by complying with procedures, rules and regulations.
• Perform all work functions and interactions using a trauma informed approach.
• Display professionalism when representing PermiaCare and the program in the community.
• Maintain compliance with legal requirements and company policies and procedures.
• Maintain valid and current driver's license, auto insurance, acceptable driving record and reliable transportation at all times. Driving may be required for this position.
• Complete all training as assigned prior to due date.
• Other duties as assigned.

MARGINAL DUTIES AND RESPONSIBILITIES (theseduties are not designated as essential for the purposes of ADA; they are stillrequired duties):

• Fill in for other MH as needed.
• Learn and apply, through center training and independent study of provided Medicaid materials, the Medicaid covered services for this position, the proper application of these services, and the codes used to describe these services.
• Progress notes clearly show progress or lack of progress in accordance with current provider agreement. (Meeting Minimum Requirements of Current Internal Provider Agreement).
• Perform crisis services as needed.
• Discharges and discharge summaries are completed when needed and in accordance with regulatory guidelines.
• Identify client needs and client risks through administration of TRR assessments and in collaboration with the CCBHC manager, the UM team, the IT team, and the UM committee.
• Provide translation, if applicable.
• Participate in team meeting or staffings.
• Participate in community activities and/or attends community meetings as needed.
• Participate in workgroups and committees as assigned.

KNOWLEDGE, SKILLS, ABILITIES AND COMPETENCIES:

• Knowledge of current research in assigned priority population.
• Knowledge about chemical dependency and mental health disorders.
• Knowledge of HIPAA and ability to protect confidentiality.
• Effec