Continuity of Care/PASRR Specialist

The Continuity of Care (COC) / PASRR Specialist is responsible for coordinating aftercare services for individuals discharged from inpatient psychiatric facilities as well as monitoring and facilitating PASRR (Preadmission Screening and Resident Review) requirements. This role plays a vital part in preventing hospital readmissions, ensuring smooth transitions of care, and connecting individuals to appropriate services either through The Betty Hardwick Center or community providers.

PASRR Responsibilities

• Monitor TMHP for new PE Evaluations and identify potential PASRR clients.

• Assess eligibility for PASRR services and ensure compliance with state and federal requirements.

• Collaborate with nursing facilities, agencies, and providers to meet PASRR requirements.

• Facilitate and participate in Interdisciplinary Team (IDT) meetings, including quarterly and annual meetings for PASRR Negative individuals.

• Will be able to complete intake services for PASRR Positive individuals for admission into The Betty Hardwick Center services.

• Coordinate care for mental health clients entering nursing homes or skilled nursing facilities.

Continuity of Care Responsibilities

• Provide immediate and intensive aftercare services for individuals discharged from inpatient psychiatric facilities.

• Conduct face-to-face appointments to review discharge plans, medications, and follow-up needs.

• Facilitate enrollment into The Betty Hardwick Center for individuals seeking ongoing care.

• Ensure follow-up appointments are arranged with community providers when applicable.

• Re-engage referrals who miss aftercare appointments to prevent gaps in treatment.

• Maintain accurate and timely documentation in compliance with agency standards.

Qualifications:

• Bachelor's degree (Master's preferred) from an accredited college or university with a major in social, behavioral, or human services (PREFER DEGREE IN SOCIAL WORK).  Prefer one year of full-time work experience in the human services field, preferably including case management experience.

• Must be able to be a Qualified Mental Health Provider 

• Knowledge of PASRR processes, eligibility criteria, and regulatory requirements. 

• Experience in mental health services, psychiatric aftercare, or continuity of care preferred. 

• Strong organizational skills with the ability to manage multiple priorities and meet strict deadlines.

• Excellent verbal and written communication skills. 

• Ability to build rapport and engage with clients, families, and community providers. 

• Familiarity with local community resources and providers. 

• Must possess a current Texas driver's license and qualify for Center coverage.

• Must have an insured personal vehicle to be used for Center duties/responsibilities.

 Hours for this position are Monday - Friday, 8am-5pm, flexible.

This is a Full-Time position. Benefits are available.

Will be eligible for a one- and two-year step increase, depending on satisfactory performance.