Care Coordinator

JOB SCOPE:As a member of the Care Coordination team and under the supervision of the Program Supervisor, the Care Coordinator for Health Home Plus (HH+) is responsible for providing intensive services to members on court ordered Assistant Outpatient Treatment (AOT) status. The HH+ Care Coordinator is responsible for addressing all member needs, providing care plan updates, conducting outreach to members in between visits, regularly communicating with collaterals and complying with all statutory requirements of Kendra’s law. HH+ Care Coordinators advocate and support members, engage with community agencies/health care providers and others on the member’s behalf to ensure access to services needed to increase wellness self-management, reduce emergency room visits and/or hospitalizations and keep the member safe within the community.ESSENTIAL FUNCTIONS:Performs other duties, consistent with the goals and objectives of the program, as may be assigned by the Director/Assistant Director. coordinates care for a caseload of approximately 12 to 15 AOT mandated members;provide face to face contact at least once per week;communicate with managed care plans about their members;collaborate with each member’s assigned AOT worker, including the timely submission of weekly reports, monthly verbal status updates, and significant event reports;comply with all statutory reporting requirements under Kendra’s Law;ensure transitions and service engagement comply with the individual’s AOT order;timely completion of CAIRS assessments;establish and maintain effective communication with primary and specialty care physicians, substance abuse and mental healthcare providers, family, collateral resources and other Agency staff on behalf of members;maintain documents, records, statistics, and other related reports in an organized, timely and accurate manner as per policy and procedure;conduct initial and periodic needs assessments, including assessing barriers and assets (i.e. transportation, community barriers, social supports); member and family/caregiver preferences and language, literacy, and cultural preferences;assist with the development and execution of member’s care plans, including assisting members in understanding care plans and instructions and tailoring communications to appropriate health literacy levels;record client progress according to measurable goals described in his/her care plan;assist members with accessing healthcare and social systems, including arranging for transportation and scheduling and accompanying members to appointments;assist members with identifying available community-based resources and actively manage appropriate referrals, access, engagement, follow-up, and coordination of services;assist with coordinating members’ access to individual and family supports and resources;assist members with managing daily routines related to healthcare and incorporating members’ strengths and identifying barriers;assist with conducting outreach and engagement activities that support continuity of care, including re-engaging members in care if they miss appointments and/or do not follow-up on treatment;provide crisis intervention and follow-up;monitors member entitlements, insurance, and other benefits to ensure they remain active and in place;advocate for members to resolve crises;collaborate with other professionals to evaluate members’ medical and/or behavioral health condition and to assess member needs;responsible for the on call 2 to 3 weeks out of the year;manage wrap around funds, metro cards and checks for member purchases including obtaining the necessary approvals for all purchases in keeping with the member’s goals.KNOWLEDGE:Knowledge of Health Home Care CoordinationKnowledge of Medicaid, Social Security and other entitlements.Knowledge of community resources available to the population served.Computer literacy; including Office programs and EHRs.SKILLS AND ABILITIES:Excellent oral and written communication skillsStrong engagement and advocacy skills.Flexibility and good crisis intervention and management skills.Excellent interpersonal skills.Ability to use good judgment in seeking supervisor assistance when appropriate.Well organized with attention to detail.Strong time management skills. Able to work effectively to manage workload under pressure and meet deadlines.Ability and willingness to travel regularly, in some instances with clients, to many locations using various modes of reliable and safe transportation.Ability to work with multiple electronic health records.EDUCATION AND EXPERIENCE:EducationA bachelor’s degree in one of the below listed fields #J-18808-Ljbffr