Care Coordinator

Job Title/Position: Health Home Care Coordinator

Reports To: Social Services Supervisor/Chief Operating Officer

Job Description Summary

The role of the Care Coordinator is to reduce gaps in services and increase coordination of all service providers including medical, behavioral health, long-term services and supports, and other social services. The Care Coordinator works with eligible clients to implement an integrated health action plan. The goal of the Health Home program is to improve the coordination of care, and quality, and to increase an individual’s participation in their own care. The Care Coordinator will travel to client homes throughout the Heartlinks Health Home service area.

Essential Job Functions/Responsibilities

• Develops and implements a case management plan in collaboration with the client, caregiver, physician, and/or other appropriate healthcare professionals, as well as the client’s support network to address the client's needs and goals.
• Performs ongoing monitoring of client’s health action plan to evaluate effectiveness, documents interventions and goal achievement, and suggests changes accordingly.
• Engage clients in care coordination activities designed to promote improved utilization of health care services.
• Performs initial and monthly home visits with clients.
• Identifies and addresses barriers to overcome impediments to accessing health care and social services.
• Provides referrals and advocacy for clients to community long term services and supports, which includes family caregiver programs, nutrition programs, etc.
• Develops and maintains relationships with community agencies and organizations that have the potential to provide resource support to clients.
• Works collaboratively with the Health Home Interdisciplinary Team by meeting regularly to assess client needs and progress.

Position Qualifications

• Bachelor of Social Work degree required, Master of Social Work degree preferred.
• Minimum of two years experience providing direct human services.
• Ability to establish and maintain effective working relationships with clients, families, and caregivers.
• Skill in interviewing clients in person or via telephone in order to elicit information and impact client situation.
• Ability to research and propose solutions to a variety of clients.
• Ability to travel to client homes and community agencies.

Benefits

• Full-time employees accrue up to 168 hours of PTO annually, in addition to accruing sick time at the rate of 1 hour for every 40 hours worked. Bereavement and jury duty leave are also available.
• Option to enroll in medical, dental, vision, and life insurance. Heartlinks pays for 100% of the employee's medical premium for the base plan and 75% of the employee's dental and vision premiums. Health benefits begin the first of the month after the start date.
• Mileage reimbursement.
• Holiday pay for 6 observed holidays.
• Ability to enroll in 401(k) and begin contributing at the time of hire. Heartlinks will match dollar for dollar up to 5% of earnings after one year of employment and 1080 hours worked.
• Tuition reimbursement/professional development assistance.
• Premium pay for hospice-related certifications.
• Hourly wage is dependent on experience; the wage range for this position is $26.00 to $33.00 per hour.