JOB DESCRIPTION

TITLE:                       Discharge Coordinator

REPORTS:                Clinical Director

DEPARTMENT:      Clinical

FLSA CODE:             Non-exempt

PRIMARY DUTY:    Direct Care

PROGRAM:               820 Programs 

MAJOR FUNCTIONS:

The Discharge Coordinator is responsible for guiding consumers and their families through the health care and supportive housing system by providing referrals, assisting with access issues, developing relationships with service providers, and tracking interventions and outcomes.  The Discharge Coordinator assumes a central role in ensuring community based services and supports are available for those consumers participating in the Reintegration phase and/or prior to discharge.  S/he works directly with consumers in individual and group sessions on issues surrounding discharge planning, identifying community based supports and securing appropriate living arrangements.  

SPECIFIC DUTIES & RESPONSIBILITIES:

1. Monitor and evaluate consumer needs, including prevention, wellness, medical, mental health, care transitions, and social and community services where appropriate.
2. Maintain up-to-date consumer charts including referrals and outcomes. 
3. Support adherence to treatment plan recommendations 
4. Responsible for ongoing consumer discharge planning.
5. Review and generate daily referrals.
6. Coordinate schedules, troubleshoot conflicts and ensure compliance with all appointments for designated consumers.

1. Develop and facilitate Independent Living Skills workshops to build skills and increase knowledge related to activities of daily living, ability to access community-based resources, spending habits and money management.
2. Assist consumers in navigating the subsidized housing identification and application process.  This includes completing 2010e applications on all residents seeking subsidized housing. 
3. Assist consumers in filling out all necessary paperwork, accompanying residents to interviews, following up with supportive housing agencies and ensuring that all housing units applied for are safe and affordable.
4. Link consumers to instrumental support services such as Medicaid, Medicare, Social Security, food stamps, home health care, Senior Citizen Rent Increase Exemption (SCRIE) and home delivered meals prior to discharge.
5. Link consumers to psychosocial/healthcare support services (e.g. SUD recovery supports, aftercare, mental health, primary care, social adult day services, senior centers, etc.) prior to discharge.
6. Attend regularly scheduled staff meetings and case conferences.
7. Attend all required in-service training seminars.

1. Participate in quality improvement activities. 
2. Other relevant duties as assigned.

REQUIREMENTS:  EDUCATION/TRAINING AND EXPERIENCE KNOWLEDGE, SKILLS AND ABILITIES

1. Bachelor’s Degree or Associate’s Degree with two (2) years of related experience in health insurance, care coordination, entitlement, or housing placement services for low income and/or homeless populations.  
2. Experience providing service coordination and information, linkages, and referrals for community-based services.

1. Knowledge of city, state, and federal guidelines for public and private low-income housing, entitlements and health insurance.  
2. Ability to research and network with other agencies/community based services to meet a variety of client needs.  
3. Proficiency with computer operation (Microsoft Word, Excel, AWARDS, and Outlook programs). 
4. Excellent written and verbal communications skills. 

1. Must be able to work a flexible schedule.  
2. This position requires regular travel throughout the five (5) boroughs.