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- Meets with perinatal clients and children in a variety of settings including: medical clinics, hospitals, client homes and community settings based on client preference.
- Enrolls and engages perinatal clients and children in a Care Coordination model that includes: Health Risk Assessment (HRA), Comprehensive Needs Assessment (CNA) and related Comprehensive Care Plan (CCP) that supports client access to needed services and implements client centered SMART (Specific, Measureable, Achievable, Realistic, and Timely) goals.
- Conducts assessment of social, material, and healthcare needs to collaboratively with the client develop a referral and Comprehensive Care Plan that identifies priorities, lists and tracks client SMART goals, and assist clients in overcoming barriers to health and well being.
- Has knowledge of and explains the benefits of available social service and medical referrals, services, programs and client eligibility criteria.
- Conducts outreach to medical and social service providers to create new partnerships that benefit patients and the Care Coordination program.
- Encourages the client to participate in perinatal home visiting programs, partening education classes, breastfeeding support, setting up Advance Directivies, Disater Prepardness Plans and other social service and medical referrals.
- Follows up on client referrals to: confirm referral was received, that the patients insurance covers the referred practitioner, and assists the patient with hotel, transportation, child care, or other barriers to her attending in-person appointments.
- Builds a trusting partnership with clients, medical providers, social service providers, and other social supports.
- Supports patients in creative ways including: being a support person upon patient or medical team request, attending Labor and Delivery if needed, accompanying the patient at other medical, social service, or behavioral health appointments, and completes, submits and manages Medicaid (or other) transportation and lodging requests for patients.
- Assists patients with home telehealth technology set up and usage including: helping patients enroll in necessary programs/applications, connecting, testing troubleshooting and getting help as needed for home telehealth communication and reporting.
- Maintains a required caseload of 32-40 active clients.
- Implements and documents the Care Coordination model to full fidelity.
- Displays openness and implements feedback as directed by supervisor, Care Coordination auditors, and insurance billing department.
- Follows policies and procedures to collect and report required patient data and in implementing the Care Coordination model to fidelity.
- Is comfortable with detailed reporting and using a computer to input client data during client meetings.
- Is comfortable asking personal questions and working with diverse clients.
- Provides stigma-free, trauma-informed, health literate, and culturally/linguistically/developmentally appropriate care and services to clients and their children.
- Maintains confidentiality of medical records and personal information in compliance with HIPAA, both electronic and paper records.
- Identifies risk factors and safety issues and educates, informs and intervenes as necessary following guidelines and protocol of medical or social service providers, including reporting abuse and neglect.
- Actively participates in clinical team meetings, case conferences, trainings, networks, grand rounds, continuing education, and conferences to maintain or improve quality services and delivery systems.
- Is committed to becoming certified as a NM Department of Health Community Health Worker within one year of hired if asked to do so.
- Work with supervisor, auditors, payors, clinics, and billing departments to ensure that Care Coordination is contracted for and billed to insurance/Medicaid.
- Other Duties as assigned.
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