Care Coordinator - Pathways

Lifeline Connections is a community-based behavioral health organization that specializes in providing confidential and compassionate care to individuals who experience substance use and/or mental health conditions.

Our Vision - As the premier provider of substance use and mental health services in the Pacific Northwest, we are respected and the most trusted resource for behavioral health treatment and whole-person care. We provide a comprehensive continuum of coordinated quality services, foster enduring relationships, and empower our communities to truly thrive.

Our Mission - Through superior customer service, high quality programs, and well-trained and dedicated staff, we inspire hope and support lifesaving changes for people affected by substance use and mental health conditions.

POSITION TITLE: Pathways Care Coordinator Non-Exempt Position

RESPONSIBLE TO: Recovery Supports Program Director

MAJOR DUTIES: This position provides care coordination to agency patients or persons requesting services. Care Coordinators (CC) are designed to utilize the Pathways model to provide support to patients. Care coordinators work one-on-one with patients to help them better self-manage their health through coordination with their providers and education on local resources.

In fulfilling these duties, the incumbent performs the following duties independently:

• Care coordinators will provide outreach and initial Community Needs Assessments resulting in the development of a client profile and initial checklist.
• Additional health screens can include the Patient Activation or Caregiver Activation Measure (PAM/CAM), Patient Health Questionnaire (PHQ-9) and the KATZ measure for activities of daily living. Other screens may be used as appropriate for care. The patient checklist will be updated at every visit;
• Supporting the patient in attaining short and long term goals. Motivational interviewing techniques will support goal setting. The CC will spend time advocating, educating and supporting the patient and natural family supports to attain and improved self-management skills;
• Provide cultural mediation between communities and the healthcare service system, culturally appropriate and accessible health education and information, informal education, counseling and social support and advocacy for individual and community needs;
• CC’s are a part of and familiar with the communities they live and work with; they are comfortable working in team environments, while building trust with their community members, local service organizations and healthcare providers to build individual and community capacity;
• As a routine part of working with the Pathways model, the CC, led by the community member, will assess needs and establish a series of Pathways, often requiring referrals to partner organizations that specialize in providing specific health or social services. An essential part of the CC role is to establish solid relationships with key staff people throughout their entire referral network of organizations in order to ensure their ability to follow up on the community members’ status once referred to an external or internal referral partner;
• The CC, in consult with contact person(s) from referral partner organizations, will use the CCS HUB Connect software to track the number of referrals, both internally and to other external organizations, and assure that the referrals are completed by using Pathways;
• CC will meet ongoing both in person and telephonically to support patient and the patient attainment of health care goals. Required to complete minimum of one (1) home visit or community visit with participants, every 30 days, considerate to agency’s physical distancing guidelines;
• Coordinate with the authorizing and health care or social service entities as necessary to maintain self-care and support the patient’s goals;
• Focus on several key indicators of health, both medical and social, called pathways. Care coordinators support patients in working through specific pathways to ultimately improve their health outcomes;
• Care Coordinator will document patient progress and recommendations in the Pathways care coordination system. All in person and telephonic encounters will also be documented;
• Attend HealthConnect monthly meetings and required trainings;
• Utilize HealthConnect / HUB Connect Software to track referrals;
• Carry a caseload (As an example, a full-time CHW/Peer could carry a caseload of 40-60 moderate risk community members, or 25 very high-risk individuals). Exact caseload size will be fluid, based on duties assigned and acuity of persons’ served in consultation with Program Director; and
• Other duties as assigned.

KNOWLEDGE AND SKILLS REQUIRED BY THE POSITION

• Possess a high school diploma or equivalent and 2 years of experience working in a related field/profession;
• Associates or Bachelor's degree in a related social service field preferred but not required;
• Above average Microsoft Office skill set;
• Experience working within health systems or providing case management;

• Experience with underserved, transient populations;
• Unencumbered driver’s license and the ability to become an approved driver per agency policy;
• Familiarly in Motivational Interviewing techniques; and
• Strong communications skills.

GUIDELINES

This position also requires the incumbent to have a valid driver’s license with a good driving record and a, insured private vehicle in order to fulfill the duties of the position.

COMPLEXITY

The incumbent provides care coordination services to patients who differ widely in age and socioeconomic status and who may possess a variety of chronic and serious social, behavioral, psychological and physical health issues. Strong clinical skills, sound judgment, and creativity are required to help implement and deliver services that meet the complex needs of the patients.

PERSONAL CONTACTS

Contacts are with the members of the treatment team, patients, significant others of the consumers, representatives of various community agencies specializing in the treatment of substance use and mental health conditions, and related community representatives including hospital personnel, primary care physicians, social services agencies etc. All contacts are carried out in accordance with federal and state laws dealing with the confidentiality of patient records.

A comprehensive discussion of boundaries and limits is integrated into the training curriculum. This discussion stresses the need for CC’s remain within the limits of their role and abilities, even when they encounter situations where they want to provide additional assistance. CC’s recognize and respect the limits of their skills and abilities, and the boundaries and limitations of their role. They are willing to set boundaries or limits between themselves and their community member(s). Boundaries create the size, space and timing (the sphere) of the CC involvement or interaction with the community member. All CC’s (Pathways service providers) receive basic training in areas such as cultural humility, substance use, reporting child abuse and neglect, domestic violence, and services in their community.

PHYSICAL DEMANDS

Most of the work can be performed while sitting and talking. The position requires the ability to travel within the community.

WORKING ENVIRONMENT

Working hours are spent indoors in the community and patient homes. Visits to community agencies, and participation in staff retreats and staff development activities will also be required.

CC’s are expected to dress appropriately for the home or community setting in which they are working. Examples include not wearing high heels and/or wearing a minimum of expensive jewelry. This may vary by situation.

For safety reasons, the CC is required to carry a cell phone (agency issued) when making in-person visits. Cell phones may be used to notify the appropriate resources in the case of medical issues, safety concerns, and to assist community members who have no phone to be able to schedule appointments.

IMMEDIATE SUPERVISOR: Recovery Supports Program Director

Salary: $20.65 - 30.98/hr DOE

Application Process:
To apply electronically for this position, please click "Apply Now" or visit our ADP career center. For more information on this and other positions, please visit our website at www.lifelineconnections.org

The Benefits:

Lifeline Connections strives to be your employer of choice by offering our regular/full-time employees a generous benefits package. Our plans cover 85% of medical, dental, and vision costs at the employee level and 75% for all dependent plans. The majority of out-of-pocket costs (i.e. co-pays, prescriptions, and deductibles) under our medical plans are also covered. We also offer other benefits, such as: employer paid Short Term Disability, Long Term Disability, Life Insurance, and supplemental coverage.

Our full-time employees and some part-time employees also qualify for our 401(K) plan that matches dollar for dollar up to 5%. On top of all that, our full-time employees receive approximately 4 weeks of paid time off during their first year of employment (accrual rates increase with years of service), as well as 1 personal holiday and 12 paid holidays per year!

There are many other supplemental benefits we are glad to offer such as tuition reimbursement and discounted cellular service amongst others.

Send us your resume and let's talk about you joining our team!