**Employment Type:** Part time **Shift:** Rotating Shift **Description:** **Care Coordinator – St. Peter's Hospital - Per Diem - Rotating** Under the direction of the Supervisor of Care Coordination and the immediate supervision of the professional nursing and social work staff, provides follow up to progress complex discharge planning needs through the continuum of care by securing the clinically required placement, services and/or equipment needed. Supports the licensed staff by completing concrete tasks necessary to facilitate the seamless transition of patients to post-acute care. In addition to supporting patient care coordination activities, responsibilities include completing departmental performance improvement activities. These activities include daily monitoring of metrics and maintaining the daily Performance Improvement boards. The incumbent will be responsible for completing chart audits and reporting the findings to leadership, working on the most complex of transitional care plans in tandem with licensed staff. This position is responsible for assisting in all aspects of transitional care planning under the direction of licensed staff. **Position Highlights:** + **Quality of Life:** Where career opportunities and quality of life converge + **Advancement:** Strong orientation program, generous tuition allowance and career development + **Work/Life:** Positions and shifts to accommodate all schedules **What you will do:** 1. Assist licensed staff with the assessment of patients and the development and implementation of the treatment and discharge plan. + Collaborate with clinical care teams to review for medical necessity and medical appropriateness of mental health and chemical dependency services available to patients and to assist in the development of after-care and follow-up plans, in accordance with mental health parity guidelines. + Makes referrals to inpatient and outpatient treatment programs when the need is identified by licensed staff. + Follows up on all referrals made to ensure an appropriate bed is in place for day of discharge 2. Functions as member of the interdisciplinary care team + In collaboration with care team, makes referrals and revises as patient’s needs change. 3. Provides Care Coordination to reduce fragmentation of care. + Makes timely referrals under direction of licensed staff to inpatient and outpatient treatment programs and community services (i.e.: Capital Region Health Connections Health Home, P.S.C.C., county or private mental health treatment settings, SPARC services, Dept. of Social Services, housing/shelter services, home care agencies, domestic violence services, Primary Care Case Managers, etc.) under the direction of licensed staff. + Coordinates timely transfers to appropriate levels of care as indicated by clinical needs and utilization criteria, in accordance with interdisciplinary team assessments, hospital policy and applicable state and federal guidelines and regulations. (i.e.: inpatient psychiatric setting, crisis evaluation, nursing home, home with supports, etc.) + Assists with facilitation of patient care transitions across the care continuum within SPHP and the patient’s community of choice, and to least restrictive most independent environment possible. + Develops and maintain knowledge of and understanding of Hospital, Organization, and community resources and facilitates us of the most appropriate level of care to conserve patient, hospital, and payer resources. + Documents referral information in a timely manner in accordance with department standards, including referral date/time, contact name/number/fax, response of referral and patient interaction/awareness of referral outcome. + Advocate for and facilitate discharge or transfer to appropriate level of care, i.e.: psychiatric facility, crisis evaluation center, housing, shelter, care facility, home with services and supports. + Assist the licensed staff with disposition based on safety related to presenting issues, i(.e: CPS, APS, Detox, Domestic Violence, Caregiver Burden, Mental Health/Substance Use Disorder, and homelessness); in accordance with hospital, SPHP, and regulatory guidelines; this may include pre-screening and referring to in-hospital Detox Service for determination of inpatient or outpatient treatment. **Other Responsibilities:** + Faxes and photocopies medical record information to facilitate discharge planning process and post-hospital care arrangements. + Assists in the coordination of departmental Quality Improvement activities + Coordinates arrangement of durable medical equipment. + Contacts insurance providers for authorization information as requested. + Makes referrals for financial assistance, entitlements and medication assistance as requested + Assists in facilitating transfers to facilities by checking bed availability daily. + Documents discharge planning process using Allscripts electronic discharge planning system. + Develops strong working relationships with various community agencies in order to promote expedient discharges. **What you will need:** **Education Requirements:** + High School Diploma required, Associates Degree or Bachelor's degree in a health-related field preferred. + Home Health Care Coordinator Requires Bachelor's Degree **Experience Requirements** : + Two years minimum experience in a health care setting, with acute care focus preferred. + Working knowledge of community resources, including but not limited to: Domestic Violence, CPS, APS, caregiver support, substance use disorders and behavioral health services, homelessness. + Demonstrated ability to communicate effectively both written and verbally. + Ability to effectively utilize multiple EMR platforms. + All new employees are required to undergo and pass all applicable state and federally mandated pre-employment screening requirements. Pay Range: $19.20 - $25.08 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. Our Commitment to Diversity and Inclusion Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions. Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity. EOE including disability/veteran