Care Coordinator

Description

A Care Coordinator works closely with medical providers, primary care teams, and social services agencies to provide short term care coordination and connection to resources and support to program clients to improve their health and general well-being through education and provision of coordination of care and services. May act as a peer support worker, where applicable, if self-disclosed as current or former consumer of mental health or substance abuse services with at least two years of mental health or substance abuse recovery.

Case Management

• Assists clients in their community, or clinic setting. Communicates to clients/patients the purposes of the program and the impact it may have on their wellbeing.
• Helps patients identify socio-economic issues that affect their overall health and develop health/social management plans and goals
• Assist with facilitating patient care through implementation of care plans and follows up accordingly
• Assists patient in understanding care plans and instructions. Motivates patients/clients to be active and engaged participants in their health and overall wellbeing.
• Communicate patient needs, determined by the assessment, to patients, families, physicians, and nurses to ensure high quality care
• Documents all client encounters and contracts made on behalf of clients; completes and submits monthly reports; maintains comprehensive electronic client files, which include client notes, release of information, assessments and other medical documents acquired on behalf of the client according to department policy
• Educates client on the proper use of the Emergency Room, and provides information for alternatives
• Coaches patients in effective management of their chronic health conditions and self-care.
• Assists clients in accessing health related services, including but not limited to: obtaining a medical home, providing instruction on appropriate use of the medical home, overcoming barriers to obtaining needed medical care and /or social services
• Provides support and advocacy during initial medical visit or when necessary to assure clients' medical needs and referrals required are being conveyed. Follows up with both clients and providers regarding health/social services plans
• Facilitates communication and coordinate services between providers and the clients/patients.
• Coordinates and monitors services, including comprehensive tracking of clients' compliance in relation to care plan objectives
• Performs miscellaneous job-related duties as assigned
• Assist with providing onsite crisis intervention and emotional support as immediate health needs arises, coordinate behavioral and mental health referrals to appropriate specialists
• Maintains accurate and timely records including clinical and progress notes
• Assist with discharge plans upon completion of treatment
  
  

Other Skills

• Comfortable working independently and collaboratively
• Possesses refined problem-solving skills
• Effective and clear communication skills (i.e., written and verbal)
• Interviewing skills
• Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community
• Knowledge of community agencies and resources
• Ability to communicate medical information to health care professionals and care coordinators over the telephone and in person
• Ability to organize resources and establish priorities
• Possesses and can demonstrate creative and analytical thinking skills
• Performs miscellaneous job-related duties as assigned by supervisor
  
  

Requirements

• High school diploma or GED; at least 1 year of experience directly related to the duties and responsibilities specified. Completed degree(s) from an accredited institution that are above the minimum education requirement may be substituted for experience on a year for year basis.
• Skill in use of personal computers and related software applications, including e-mail.
• Skill in organizing resources and establishing priorities.
• Creative and analytical thinking
• Preferred
• 3 years case management experience
• Healthcare experience