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Hospital Discharge Care Manager – Behavioral Health

Hospital Discharge Care Manager – Behavioral Health


denova Collaborative Healthcare is committed to improving lives and transforming healthcare.  We utilize our Core Values as the foundation for all we do:

Compassionate:  Compassion is the humane quality of understanding the needs of others, and wanting to do something about it.  We show kindness and a willingness to help others.  We always provide care for our colleagues, our patients and our community.

Adaptable: The ability of our team to adapt to different environments, conditions and changes is imperative to deliver high quality care.  Adaptable people are open to others while realizing the impact of their own words, tone and body language on others.

Innovative: Our team must have creative and critical thinking in order to introduce new ideas.  Our commitment is creating a comprehensive healthcare delivery system like nothing done, experienced or created before.

Reliable:  As a patient and community centric organization, being reliable is of the utmost importance.  In order to achieve results, we must have a team comprised of consistent and trustworthy individuals that can be counted on to follow through.

Relentless:  We have an unwavering commitment to improve the healthcare system, disrupt the status quo, and create a better community.  We are driven individuals that exemplify intensity and the pursuit of excellence.  A strong work ethic and enthusiasm are necessary in order to help our patients, improve our community, and accomplish our goals.


The Hospital Discharge Care Manager promotes quality and value of care by engaging and educating patients to manage their health.  The position is a key part of the Population Health team, collaborating with Behavioral Health and Psychiatry.  The care manager performs comprehensive evaluations of patients at care transitions, monitors quality measures, and communicates with patients who have identified care needs. This individual is able to skillfully motivate patients to become active participants in their healthcare.

Primary Job Responsibilities:

  • Manage patients discharged after psychiatric and substance abuse related hospitalizations including medication reconciliation and patient education to avoid readmission
  • Perform intakes on psychiatric patients after change in status including hospital discharge or ER visit
  • Follow up and reschedule patients who miss their 7 or 30 day Follow Up after Hospitalization or ED visit
  • Complete annual updates for patients receiving psychiatric services only
  • Provide outreach and engagement for patients on health plan rosters who have not been seen at denova
  • Collaborate with Integration Specialist to ensure patients receive warm and prompt engagement in behavioral health
  • Participate in patient outreach and review of records to identify and close gaps in quality measures
  • Availability for intakes on other patients as needed


Education, Certification, and Experience Requirements

  • Bachelor’s degree in nursing, LPN, counseling, psychology, social work or related field preferred or
  • Licensed Practical Nurse with active and current licensure by the AZ State Board of Nursing
  • Qualified as a Behavioral Heath Technician required
  • Experience with coordinating care with inpatient teams
  • Bilingual a plus
  • Exceptional communication skill with the ability to engage patients in their medical care
  • Exceptional time management skills
  • Exceptional problem-solving skills and the ability to work within an interdisciplinary team
  • Must have a valid Arizona Fingerprint Clearance card
  • Demonstrated ability to work independently

Tools and Equipment Requirements

  • The ability to use a phone, computer, printer, and copier is required.
  • Frequent use of Microsoft office products, including but not limited to Outlook, Word, Excel, and PowerPoint.
  • The ability to use the internet and various web browser software is required.

Physical Working Conditions and Office Setting Description

  • Some travel required to field locations to facilitate execution of responsibilities. Must provide proof of a valid driver’s license, valid auto insurance with, at minimum, state required insurance levels.
  • Requires prolonged sitting, standing, frequent bending, stooping, or stretching.
  • Some lifting may be required.
  • Frequent and prolonged typing and frequent and prolonged operation of computer, keyboard, and telephones required.
  • Requires occasional use of fax machines, telephones, copiers, and other office equipment.
  • Employee must regularly lift and/or move up to 10 pounds, frequently lift and/or move up to 25 pounds and occasionally lift and or move up to 50 pounds.

Other Conditions

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

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