Job Description

Disengagement and Discharge Specialist

Join a Healthcare Force for Good!

$24.72-$30.21 per hour

A nationally recognized comprehensive Health and Human Services Agency, with over 60 programs across New York City and greater New York Area.

Samaritan Daytop Village serves over 33,000 New Yorkers annually within your neighborhoods and communities, so our success depends on those we employ.

The Role

The Disengagement and Discharge Specialist (DDS) provides an important service to Hope Care Management members who are disengaged from care coordination services. The Disengagement and Discharge Specialist has a caseload comprised of members who are either designated as disengaged or are nearing their graduation from the care coordination program. The DDS attempts to reengage members of the Hope Care Management program who are in “diligent search/ pending status” while also disenrolling or graduating from Care Coordination services, after any amount of time. If a member is successfully re-engaged with the DDS, the DDS will update the care plan with any relevant goals and subsequently notify the Outreach and Systems Manager to transition the member back to the original assigned Care Manager or Patient Care Navigator, or original team of the assignment.

Once a member is identified as nearing the graduation stage of care coordination services, the member will be transitioned to the DDS for the final 1-2 months of service provision. The DDS reviews the client's discharge plan, closes out their Care Plan, makes any necessary adjustments to the Comprehensive Assessment, sends out a full packet of information on existing providers, upcoming appointments and important numbers, and also provides information on re-enrollment. After all of these tasks are complete, the Disengagement and Discharge Specialist completes the appropriate forms to officially inform the client of their discharge and remove consent where necessary. The majority of the Discharge Coordination services are provided via travel, phone and email, from an office-based setting, although in-person meetings may be needed. This work is carried out in support of the mission and goals of Samaritan Daytop Village.

Responsibilities

What You Will Do

• Develops, adheres to, and documents daily schedule of interventions; informs supervisor of scheduling conflicts or changes and maintains accurate record of daily activities using the Outlook calendar resource.
• Completes the appropriate forms and additional paperwork to formally discharge a client from programming, and ensure revocation of consent wherever necessary, in accordance with policy.
• Edit or complete client centered comprehensive functional assessments, as needed, to identify the medical, behavioral health and social needs/goals of each client at the time of discharge.
• Review and update written/electronic person-centered care plans. Ensure that all Care Plans uphold the policy and procedure set forth by the department, and that a final copy is provided to the client at the time of discharge.
• Utilizes the Electronic Health/Medical Record, Avatar and other required platforms to ensure accurate documentation.
• Utilizes the appropriate documentation format for each member and ensures timely documentation of each encounter.
• Responds to inpatient and ER admission alerts and contacts medical provider/hospitals for admission/discharge information.
• Recognizes member as a contributing member of care team through motivational interviewing techniques, continuous transference and reinforcement of self-management skills.
• Provides support to member and family, including but not limiting to locating resources to eliminate barriers and advocating on behalf of member and their supports to ensure they have supports necessary to improve their health.

Qualifications

Who You Will Be

• Bachelor's degree in human services or related field such as child and family studies, community mental health, counseling, education, nursing, occupational therapy, physical therapy, psychology, recreation, recreational therapy, rehabilitation, social work, sociology, or speech and hearing
• OR
• NYSED licensed Registered Nurse and a Bachelor´s Degree
• OR
• Bachelor´s level education or higher in ANY field with Five (5) years’ experience working directly with persons with behavioral health diagnoses.
• OR
• An OASAS Credentialed Alcoholism and Substance Abuse Counselor (CASAC)
• Flexibility is needed as members may call outside of daily work schedule (24-hour call).
• Willingness to travel to members’ homes as needed.
• Ability to complete mandated training on the New York State Community Mental Health Assessment Instrument and additional required training.
• Computer literacy including proficiency in Microsoft Office Suite and EHR.
• Experience working directly with people from diverse racial, ethnic and socioeconomic backgrounds.
• Competency in written, interpersonal, verbal and computational skills to present and document records in accordance with program standards.

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