Integrated Care Coordinator

Job Description

Job Description

About Company :

We are looking for mission driven professional leaders who want to be part of a collaborative and dynamic team. Regardless of title, you will be a vital member and leader of a powerful team. Southeastern Integrated Care is dedicated to providing quality care and support to individuals struggling with behavioral health disorders , substance use disorders, and chronic medical conditions. By joining us, you would have the opportunity to make a significant impact on the lives of those in need, helping them on their journey to recovery, and improved mental well-being. We pride ourselves on having a team of committed and highly trained professionals who are passionate about making a difference in the field of behavioral health, substance use disorders, and chronic care . Working alongside such a team would foster a collaborative environment where you can exchange knowledge, share experiences, and learn from one another, ultimately enhancing your expertise and professional growth. Our supportive and empowering culture allows for us to provide cutting edge care and innovative treatment approaches

We are a company that provides our team members with a quality and comprehensive onboarding experience, amazing supervision and coaching, paid educational and training opportunities, and opportunities for advancement within our organizations. We believe that our team is number one, comes first, and that the clients and patients we serve are our number one priority. If you are a highly skilled professional with a leadership mindset, Southeastern Integrated Care is the ideal place for you to thrive, and make a difference. Our competitive salary, paid healthcare benefits options, matching 401k plan, bonus and stipend structures afford you and your family the financial support needed for you to focus on saving lives and providing the best opportunity for our clients to reach their maximum potential. If this is the type of environment you choose to work in, then Southeastern Integrated Care has a place for you.

Job Summary :

The Southeastern Integrated Care Nurse is responsible for coordinating and providing comprehensive care to patients in an advanced medical home setting. This role focuses on bridging the gap between behavioral health and primary care needs, with an emphasis on inclusive and collaborative care management, chronic care management, and remote patient monitoring. The Integrated Care Nurse works closely with interdisciplinary care teams throughout the organization and within the community to ensure the delivery of high-quality and patient-centered integrated care services. This position will provide the ultimate support of the mission and vision of our advanced medical home tier 3.

Essential Duties and Responsibilities :

• Coordinate Care : Collaborate with behavioral health providers, primary care physicians, and other healthcare professionals to develop and implement integrated care plans for patients with complex medical and behavioral health needs.
• Conduct Assessments : Conduct comprehensive assessments of patients' physical, behavioral, and psychosocial health status to identify individual needs and develop personalized care plans.
• Care Planning : Develop and implement individualized care plans that address patients' physical, mental, and emotional health needs, focusing on chronic disease management and behavioral health interventions.
• Collaborative Care Management : Facilitates communication and coordination between behavioral health and primary care providers to ensure seamless integration of services and promote holistic patient care. Acts as a behavioral health care manager champion in accordance with NC collaborative care model.
• Acts as Collaborative care behavioral health management champion / care manager.
• Acts as CCM / RPM integrated care coordinator and onboarding of services.
• Acts as nursing liaison between behavioral health clients in need of primary care via SEIC.
• Acts as nurse reviewer of all CCM, CoCM and RPM reporting.
• Onboarding patients for neuro cognitive assessment.
• Chronic Care Management : Provide ongoing support and education to patients with chronic conditions, including monitoring medication adherence, lifestyle modifications, and self-management techniques.
• Remote Patient Monitoring : Utilize remote patient monitoring technology to monitor patients' vital signs, symptoms, and treatment adherence, and provide timely interventions, as necessary.
• Patient Education : Educate patients and their families on healthcare management strategies, self-care techniques, and available community resources to promote wellness and prevent hospital readmissions.
• Documentation : Maintain accurate and up-to-date electronic health records (EHR) and documentation of patient encounters, care plans, interventions, and outcomes.
• Quality Improvement : Participate in quality improvement initiatives to enhance the delivery of collaborative care services and improve patient outcomes within the organization.
• Professional Development : Stay updated with current trends and evidence-based practices in integrated care, behavioral health, chronic disease management, and remote patient monitoring through continuous education and professional development activities.

Qualifications and Education :

Additional Training and Requirements (to be provided upon hire) :

Work Environment :

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Work is performed primarily in the client’s living environment and in the community and may involve exposure to cigarette smoke, domestic animals / pets, household pests, uncomfortable heating / cooling, and other issues related to the domestic location in which service is delivered.

Physical Demands :

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to stand, walk; use hands to finger, handle, or feel objects, tools, or controls; talk and hear; and taste and smell. The employee frequently is required to reach with hands and arms and stoop, kneel, crouch, or crawl. The employee is occasionally required to sit and climb or balance. The employee must be able to lift and / or move up to 20 pounds and occasionally lift and / or move up to 50 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. Must be able to drive and operate a personal vehicle safely and adhere to all applicable state and traffic laws.