Post Hospital Liaison; Integrated Care;330

Job Summary
This position will work closely with internal and external community partners to support clients who have experienced a psychiatric hospitalization with achieving stability and recovery support through linkage to services to overcome social drivers of health. The Post Hospital Liaison will assist behavioral staff and clients with applying for unique, but vital services and assistance in their journey of recovery.

The primary role will be to identify & outreach clients who have had a hospital presentation in the emergency department or inpatient. ,

This position will be key in reducing the readmission rate of clients and increasing the utilization of Access to Wellness funds.

Essential Job Duties & Responsibilities
• Provide outstanding quality customer service in responding to inquiries for information and referral from individuals, professionals, and organizational clients.
• Establish positive relationships with behavioral health and Emergency Department staff at local hospitals
• Persistently and firmly advocate for contacts/clients who otherwise are unable to independently access resources or who meet program eligibility criteria.
• Collaborate with Centers staff and partner agencies to assist clients in submitting, completing, applications and providing necessary documents.
• Respond to referrals of applicants including completing intake information, assessment of the client’s needs, preferences, and eligibility.
• Record necessary assessment and screening tools in the EHR and other necessary systems.
• Maintain current client data, keep detailed case notes, client files and program information up to date and organized in client database,
• Communicate regularly and effectively with the client, service coordinators, service providers, and support personnel to ensure that program requirements and resources are distributed accurately.
• Manage the notify and ADT panels daily to outreach clients post hospitalization to ensure connection to follow up services
• Collaborate with Centers staff to ensure clients receive services within seven days of discharge from a hospital event.
• Identify high utilizers and work with the care team to reduce dependence on hospital systems.
• Provide billable services to Centers clients post hospitalization when appropriate
• Provide office-based case management and counseling services as needed
• Attend training and workshops related to program improvement and professional development.

Other Job Duties & Responsibilities
▪ Other duties as assigned.

Core Competencies
▪ Situational Leader: Enables and empowers team members to develop their competency and commitment in completing goals and tasks; creates an environment of trust and mutual respect and sets an example for other leaders in the organization.
• Communication: Expresses thoughts clearly, concisely, and effectively both verbally and in writing. Presents in a confident, clear, and enthusiastic manner when addressing people in a large or small group. Demonstrates a sound knowledge of the subject matter. Demonstrates and maintains proficiency in effectively using database software, computer hardware and any job performance related technologies.
▪ Interpersonal Skills: demonstrated emotional intelligence with an ability to balance an empathy forward response with families and throughout the organization. Enjoys working closely with other people to understand their concerns and seeks out the ways our workplace might address them. Able to use storytelling to advance a concept or idea.

▪ Time management: able to balance multiple priorities and have good time management skills.

▪ Detail Oriented: has a high level of need to understand how and why things are related; the ability to process detailed information effectively and consistently. Develops ideas thoroughly and meticulously into an effective plan of action. Understands and appropriately applies principles, procedures, requirements, regulations, and policies.

▪ Values Diversity: Collaborates with colleagues, both internal and external; demonstrating a respect for divergent viewpoints; interacts well with diverse people and groups, thereby contributing to an environment that is equitable, inclusive, and cooperative. An awareness of and sensitivity to the cultural diversity of the population served. Consistently communicates positivity, caring and concern to all.
Consistently interact appropriately, respectfully, understandingly, and patiently with contacts and coworkers of diverse backgrounds, physical capabilities, emotional states, and skill levels.


Job Qualifications
▪ Bachelor’s degree in social work
▪ Ohio Social Work License
▪ Experience working with clients with SPMI
▪ Must demonstrate