- Initiate discharge planning upon admission for adult patients with acute psychiatric conditions.
- Assess psychosocial, medical, housing, and support service needs to create individualized discharge plans.
- Collaborate with psychiatrists, nurses, social workers, and other healthcare team members to assess discharge needs upon admission and throughout the patient's stay
- Coordinate referrals to outpatient behavioral health providers, intensive outpatient programs (IOPs), substance use treatment, housing services, vocational rehab, and other community resources.
- Schedule follow-up appointments with psychiatrists, primary care physicians, therapists, and case managers.
- Communicate with external agencies (e.g., community mental health centers, shelters, group homes, halfway houses) to ensure smooth transitions.
- Collaborate with insurance companies or utilization review staff to obtain authorizations for post-discharge services.
- Conduct family and support system meetings to prepare for discharge and educate support persons when appropriate.
- Document all discharge planning activities in the electronic health record (EHR) in compliance with facility and regulatory standards.
- Participate in daily treatment team meetings to communicate discharge progress and coordinate care plans.
- Develop individualized discharge plans that consider the patient’s mental health status, housing, medication needs, outpatient services, and social support systems.
- Facilitate family meetings or care planning conferences to support discharge goals.
- Ensure patients and families understand discharge instructions and aftercare plans, including follow up appointments, warning signs of relapse, and crisis resources.
- Maintain current knowledge of community resources, psychiatric treatment programs, and housing options.
- Support efforts to reduce readmissions and improve patient outcomes through effective transition planning.
- 21 years of age or older; or minimum 18 years old and licensed or certified under A.R.S. Title 32 and providing services within the personnel member’s scope of practice; or minimum 18 years old for select administrative positions
- Must be able to provide or obtain an AZDPS Level One Fingerprint Clearance Card
- Must possess and maintain a valid Driver License, current automobile insurance, and a driving record that meets the guidelines and requirements of the organization
- Bachelor’s degree in a behavioral health field or minimum 2 years of experience working with adults in a behavioral health setting, or a combination of education and experience
- Prior experience in discharge planning, case management, or care coordination preferred
- Understanding of adult psychiatric disorders, co-occurring conditions, and mental health recovery models
- Knowledge of local and regional community mental health resources, including housing, employment, and outpatient services
- Excellent verbal and written communication skills
- Organizational and time management skills; ability to prioritize multiple tasks
- Compassionate and professional demeanor; ability to work with diverse adult populations, including individuals experiencing homelessness, substance use, or severe mental illness
- People – Passionately believes in people and embraces diversity
- Integrity – Does the right thing even when no one is looking
- Learning – Challenges old paradigms with critical thinking, curiosity, and creativity
- Accountability – Sets an intentional culture of personal responsibility; believes everyone carries the load
- Relationships – Serves colleagues and consumers with love, empathy and compassion
- Office environment, travel within the community, as needed
- Heavy exposure/use of computers, cell phones, office phones, etc.
- May be required to wear protective clothing (PPE)
- Annual TB screening per program policy and procedure
- Ability to be physically mobile (stand, walk, reach, climb, bend) and the ability to sit for prolonged periods throughout work hours
- Must be able to occasionally lift and/or move 50 or more pounds
- Must be able to respond appropriately and effectively in crisis situations by using good judgment and following Polara Health protocols
- Must be able to successfully complete all physical skills components of CPI, including floor-based interventions
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights (https://www.eeoc.gov/poster) notice from the Department of Labor.
