Care Coordinator

• Accountable for engaging and retaining health home members in care, coordinating and arranging for the continuous provision of services, supporting adherence to treatment recommendations, monitoring and evaluating their needs, including prevention, wellness, medical, specialist and behavioral health treatment, care transitions, and social and community services where appropriate through the creation of an individual plan of care.
• In collaboration with the health home members, their family and/or caregivers, and other service providers develops, manages and coordinates a comprehensive individualized person-centered care plan that coordinates and integrates the continuum of medical, behavioral health services, rehabilitative, long term care and social service needs and clearly identifies the primary care physician/nurse practitioner, specialists, behavioral health care providers, care manager and other providers directly involved in the individual’s care.
• Ensures the availability of priority appointments for health home members to care services including physical, psychiatric, and substance abuse within their health home provider network to avoid unnecessary, inappropriate utilization of emergency room and inpatient hospital services.
• Reassesses needs for Health Home services and reviews health home members’ historical or targeted clinical measurements (i.e. number of ER visits and inpatient psychiatric admissions).
• Identifies potential barriers to successful care and resolutions to those barriers.
• Completes contact notes, incident reports, and other required documentation and maintains accurate recordings in electronic case files in a requested timely fashion.
• Outreach via phone to health home members between visits (check on self-care, medication fills, treatment plan, schedules visits, tests/follow-up) Monitors that the health home member completes post-visit follow-up (fill prescriptions, make appointments).
• Refer health home members to peer supports and coordinate peer supports, support groups, and self-care programs to increase client’s and caregivers knowledge about the individual’s diseases, promote the health home members’ engagement and self-management capabilities, and help the to improve adherence to their prescribed treatment order to allow them to make informed decisions.
• Assure timely and comprehensive transitional care from an inpatient facility (hospital, rehabilitative, psychiatric, skilled nursing or treatment facility) to follow-up with post discharge interventions in order to prevent health home member’s avoidable readmission after discharge and to ensure proper and timely follow up care.
• Develops and maintains health home networks with primary medical and specialty practitioners and mental health providers, substance abuse service providers, community based organizations, managed care plans, emergency rooms, hospitals, and residential/rehabilitation settings, community-based services to ensure coordinated, and safe transition in care for its patients who require transfer to/from sites of care.
• Utilizes regional health information organizations (RHIOs) and other data systems to track and share health home members’ information and care needs across providers, monitor their outcomes, and initiate changes in care as necessary to provide the health home prompt notification of an individual’s admission and/or discharge to/from an emergency room, inpatient, or residential/rehabilitation setting and address immediate needs in order to maximize optimum care and timely treatments, services and referrals.
• Utilizes and electronically tracks all specialty medical, behavioral, and support service referrals made for health home members, and ensures that the member follows up and receives all of the care they need. Tracks and arranges appointments, educate health home members and coordinate all aspects of the member’s health and community services.
• Able to utilize technology conferencing tools including audio, video and /or web deployed solutions and accountable for hand-held devices (I Phone, Blackberry, I Pad, Tablets, Laptops, etc.).
• Makes sure that health home members’ entitlements, insurance and benefits are in place. Provides interpreter services as required.
• Responsible for direct service provision of services to the consumer based on needs as established and documented in comprehensive assessments and service plans. This will be re-evaluated and adjusted every 6 month direct s or as needed (as per SOMH CAIRS requirements).
• Work schedule includes holiday coverage to accommodate the coverage needs of the program when required. 24 hours/seven days a week availability to provide information and emergency consultation services and provide escorts to health home members from ER, hospital and other settings to alternative level of care.
• Attends required in-service programs and trainings.
• Collaborate with program management in the identification of developing marketing strategies.
• Request in a timely fashion scheduled vacation and time off request from the Clinical Manager to ensure continuous coverage of program’s activities.
• Performs other related duties as requested or assigned by agency management.
  

QUALIFICATIONS:

• Bachelor’s degree in social work, psychology or a related health/human services field with two (2) years of direct work with the target population. OR Degree/certification in Medical and Clinical Assistance or Health professional field.
• Knowledge of the community medical resources and their financial requirements.
• Good oral and written communication skills.
• Fluency in second language preferred
• Ability to work flexible hours and days – including weekends/evenings/holidays according to needs of a 24/7 program.
• Able to lift up to 10 pounds.
• Able to climb stairs and make home visits.
• Able to stretch and bend to retrieve files.
• Able to operate a computer keyboard, mouse, & office equipment.
• Able to read printed materials and computer screens.
• Able to sit and work on the computer for long periods of time.
• Able to travel to multiple locations as needed.
  

BENEFITS:

• We offer competitive salary and excellent benefits including:
• Generous time off (Vacation/ Personal Days/ Sick Days/ Paid Holidays annually)
• Medical,
• Dental
• Vision
• Retirement Savings with Agency Match
• Transit
• Flexible Spending Account
• Life insurance
• Public Loan Forgiveness Qualified Employer
• Training Series and other additional voluntary benefits.