Transition of Care Clinician
Reports To:Director of Strategic Partnerships & Resource Development
Location: Long Island & NYC
Department: Transition of Care Program
The primary goal of the Transition of Care (TOC) program is to bridge the gap between an inpatient Behavioral Health discharge, and the member’s first appointment with their community provider. This visit aims to prevent re-hospitalization by ensuring the member understands their treatment plan, has their medications, and can keep their scheduled appointments. Clinician will conduct a home visit within 7 days of discharge from an inpatient Behavioral Health setting. The clinician will:
- Assess for any decompensation in function.
- If there is decompensation, collaborate with MCO to recruit appropriate supportive services to ensure safety and wellness.
- Identify and communicate to the MCO Case Manager any significant environmental stressors or deficits that could impede member’s transition back to the community and/or continued recovery.
- Review the treatment plan with the member
- Confirm availability and access to prescribed medications
- Review how to take prescribed medications
- Confirm member’s outpatient appointment with the outpatient provider.
- Connect member with case management services as applicable (e.g. Health Home)
- Review entitlements and resources
- Encourage patient follow-up with their community provider, MCO Case Manager, and Health Home Case Manager (if applicable).
Candidate must have a current and a valid license of the following LCSW, LMSW, LMFT. Clean, valid NY State Driver’s License. Fingerprinting, criminal record check, approval from NYS Office of Mental Health.
Please send your updated resume to email@example.com. Please include the title of the position you are applying for.