JOB DESCRIPTION

TITLE: Discharge Coordinator

REPORTS: Clinical Director

FLSA CODE: Non-exempt

PRIMARY DUTY: Direct Care

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.

In addition to competitive salaries, Odyssey House offers:

• A 35-hour work week (as opposed to a 40-hour work week)
• Vacation Plan and Holiday Schedule
• Life Insurance
• Medical Insurance (Two Plans)
• Dental and Vision Insurance
• Additional Insurance Coverages (hospitalization, accidental, critical illness coverage)
• Long-Term & Short-Term Disability
• Flexible Spending Account/Health Reimbursement Account
• 403(b) Plan
• Corporate Counseling Associates (CCA) EAP benefit
• Ability Assist Counseling Services (through The Hartford)
• Commuter Benefits
• Educational Assistance Programs
• Special shopping discounts through ADP Marketplace and PlumBenefits
• RUFit?! Fitness Program
• Pet Insurance
• Legal Assistance
• Optum Financial Service through ConnectYourCare
• Benefit Advocacy Center through Gallagher

Odyssey House is an equal opportunity employer maintaining a non-discriminatory policy on hiring of its personnel. Odyssey House, and its operational divisions, will not discriminate against any employee or applicant because of race, creed, color, national origin, sex, disability, marital status, sexual orientation or citizen status in all employment decisions including but not limited to recruitment, hiring, upgrading, demotion, downgrading, transfer, training, rate of pay or other forms of compensation, layoff, termination and all other terms and conditions of employment.