Care Coordinator

POSITION SUMMARY

CareLink NM is a Medicaid-funded care coordination program. CareLink is intended to enhance integration and coordination of primary care, behavioral health care, acute care, and long-term care services for individuals with a serious mental illness diagnosis along with a chronic physical health diagnosis.

CareLink NM services include comprehensive needs assessment and individualized care plan; care coordination; prevention, health promotion, and disease management; comprehensive transitional care; individual and family support service; and referrals to community and social support services.

RESPONSIBILITIES

• Carry a minimum caseload of 80 individuals at a time
• Complete a monthly billable encounter with at least 90% of assigned caseload
• Contact eligible individuals to provide education and orientation about CareLink services, and obtain and document the individual decision's about opting-in to CareLink
• Conduct Comprehensive Needs Assessment (CNA)
• Create an integrated service plan based on the CNA with the enrolled individual
• Create crisis and disaster plans with enrolled individuals
• Conduct a minimum of one encounter per month per client that supports the individual's progress towards service plan goals
• Perform all care coordination activities as needed
• Maintain clear, concise, and timely documentation adhering to all policies and procedures
• Document client interactions and encounters in the GCLC electronic health record, the State of New Mexico's NMSTAR system, and internal spreadsheets
• Maintain all client charts following the CareLink Policy Manual and GCLC requirements
• Function as the hub for the individual's care team developed in collaboration with the individual, their natural supports, and as informed by the CNA
• Engage natural supports and community resources to assist in overcoming barriers to engagement or access to care
• Engage and collaborate with all integrated care team members and conduct team meetings as necessary to make sure client's medical and mental health needs are understood by all team members
• Understand and maintain HIPAA and 42CFR Part 2 confidentiality standards
• Participate in all mental health department training and supervision
• Be proficient in all aspects of the CareLink Policy Manual and additional program-related requirements
• Perform other duties as assigned

QUALIFICATIONS

Minimum

Preferred

CONDITIONS OF WORK

Hiring and promotion will be accomplished in compliance with the GCLC's Personnel Policies and Procedures. This position is exempt under the Fair Labor Standards Act. This position requires a minimum of 40 hours per week, generally Monday through Friday. Hours or days may vary according to need. Personal transportation is mandatory. Travel may be required for delivery of services, training, or conferences.