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Mercy Medical Center Clinton Care Coordinator – St. Peter's Hospital – Per Diem Days in St. Peter's Hospital - Albany, New York

Employment Type:

Part time


Day Shift


Care Coordinator – St. Peter's Hospital

Per Diem Days

Under the direction of the Supervisor of Care Coordination and the immediate supervision of the professional nursing and social work staff, provides follow up to progress complex discharge planning needs through the continuum of care by securing the clinically required placement, services and/or equipment needed. Supports the licensed staff by completing concrete tasks necessary to facilitate the seamless transition of patients to post-acute care. In addition to supporting patient care coordination activities, responsibilities include completing departmental performance improvement activities. These activities include daily monitoring of metrics and maintaining the daily Performance Improvement boards. The incumbent will be responsible for completing chart audits and reporting the findings to leadership, working on the most complex of transitional care plans in tandem with licensed staff. This position is responsible for assisting in all aspects of transitional care planning under the direction of licensed staff.

Position Highlights:

  • Quality of Life: Where career opportunities and quality of life converge

  • Advancement: Strong orientation program, generous tuition allowance and career development

  • Work/Life: Positions and shifts to accommodate all schedules

What you will do:

  1. Assist licensed staff with the assessment of patients and the development and implementation of the treatment and discharge plan.
  • Collaborate with clinical care teams to review for medical necessity and medical appropriateness of mental health and chemical dependency services available to patients and to assist in the development of after-care and follow-up plans, in accordance with mental health parity guidelines.

  • Makes referrals to inpatient and outpatient treatment programs when the need is identified by licensed staff.

  • Follows up on all referrals made to ensure an appropriate bed is in place for day of discharge

  1. Functions as member of the interdisciplinary care team
  • In collaboration with care team, makes referrals and revises as patient’s needs change.
  1. Provides Care Coordination to reduce fragmentation of care.
  • Makes timely referrals under direction of licensed staff to inpatient and outpatient treatment programs and community services (i.e.: Capital Region Health Connections Health Home, P.S.C.C., county or private mental health treatment settings, SPARC services, Dept. of Social Services, housing/shelter services, home care agencies, domestic violence services, Primary Care Case Managers, etc.) under the direction of licensed staff.

  • Coordinates timely transfers to appropriate levels of care as indicated by clinical needs and utilization criteria, in accordance with interdisciplinary team assessments, hospital policy and applicable state and federal guidelines and regulations. (i.e.: inpatient psychiatric setting, crisis evaluation, nursing home, home with supports, etc.)

  • Assists with facilitation of patient care transitions across the care continuum within SPHP and the patient’s community of choice, and to least restrictive most independent environment possible.

  • Develops and maintain knowledge of and understanding of Hospital, Organization, and community resources and facilitates us of the most appropriate level of care to conserve patient, hospital, and payer resources.

  • Documents referral information in a timely manner in accordance with department standards, including referral date/time, contact name/number/fax, response of referral and patient interaction/awareness of referral outcome.

  • Advocate for and facilitate discharge or transfer to appropriate level of care, i.e.: psychiatric facility, crisis evaluation center, housing, shelter, care facility, home with services and supports.

  • Assist the licensed staff with disposition based on safety related to presenting issues, i(.e: CPS, APS, Detox, Domestic Violence, Caregiver Burden, Mental Health/Substance Use Disorder, and homelessness); in accordance with hospital, SPHP, and regulatory guidelines; this may include pre-screening and referring to in-hospital Detox Service for determination of inpatient or outpatient treatment.

Other Responsibilities:

  • Faxes and photocopies medical record information to facilitate discharge planning process and post-hospital care arrangements.

  • Assists in the coordination of departmental Quality Improvement activities

  • Coordinates arrangement of durable medical equipment.

  • Contacts insurance providers for authorization information as requested.

  • Makes referrals for financial assistance, entitlements and medication assistance as requested

  • Assists in facilitating transfers to facilities by checking bed availability daily.

  • Documents discharge planning process using Allscripts electronic discharge planning system.

  • Develops strong working relationships with various community agencies in order to promote expedient discharges.

What you will need:

Education Requirements:

  • Associates Degree Required. Bachelor's degree in a health-related field preferred.

Experience Requirements :

  • Two years minimum experience in a health care setting, with acute care focus preferred.

  • Working knowledge of community resources, including but not limited to: Domestic Violence, CPS, APS, caregiver support, substance use disorders and behavioral health services, homelessness.

  • Demonstrated ability to communicate effectively both written and verbally.

  • Ability to effectively utilize multiple EMR platforms.

  • All new employees are required to undergo and pass all applicable state and federally mandated pre-employment screening requirements.

Trinity Health's Commitment to Diversity and Inclusion

Trinity Health employs about 133,000 colleagues at dozens of hospitals and hundreds of health centers in 22 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Trinity Health's dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.

Trinity Health is one of the largest multi-institutional Catholic health care delivery systems in the nation, serving diverse communities that include more than 30 million people across 22 states. Trinity Health includes 94 hospitals, as well as 109 continuing care locations that include PACE programs, senior living facilities, and home care and hospice services. Its continuing care programs provide nearly 2.5 million visits annually.

Based in Livonia, Mich., and with annual operating revenues of $17.6 billion and assets of $24.7 billion, the organization returns $1.1 billion to its communities annually in the form of charity care and other community benefit programs. Trinity Health employs about 133,000 colleagues, including 7,800 employed physicians and clinicians.

Committed to those who are poor and underserved in its communities, Trinity Health is known for its focus on the country's aging population. As a single, unified ministry, the organization is the innovator of Senior Emergency Departments, the largest not-for-profit provider of home health care services — ranked by number of visits — in the nation, as well as the nation’s leading provider of PACE (Program of All Inclusive Care for the Elderly) based on the number of available programs. For more information, visit at . You can also follow @TrinityHealthMI on Twitter.