Care Coordinator - Eyerly Ball

UnityPoint Health Information

The Integrated Health Home (IHH) Care Coordinator is responsible for coordinating care for the clients we serve. The Care Coordinator works with the team to assist with client behavioral health, physical health, and social factors through a variety of modalities. Assess the client’s strengths, behavioral health, physical health, and social needs to develop and implement an individualized service plan designed to improve the client’s overall health and quality of life. The Care Coordinator is responsible for completing all annual paperwork items, including comprehensive assessment and social history and person centered service plans. The Care Coordinator is responsible for documenting goal progress and using a person-centered approach to delivering services.

Intensive Care Management Care Coordinator are responsible for overseeing Habilitation (HAB) funding and services. They submit and monitor referrals for HAB services. Once services are approved, they complete a request for HAB funding and monitor authorizations for services.

Care Coordination:

• Provide outreach activities to clients to engage in care coordination

• Conduct Individualized, comprehensive whole person assessments

• Schedule appointments

• Make and track referrals and appointments

• Monitor follow up appointments and services

• Communicate with providers on interventions/goals

• Conduct joint treatment staffing with a multidisciplinary team and client/ parent/guardian to plan for
treatment and coordination

• Support coordination of care with primary care providers and specialist

• Attending joint staffing treatment meetings
Health Promotion

• Promote clients’ health and ensure that all personal health goals are included in person-centered care
management plans

• Promote of substance abuse prevention, smoking prevention and cessation, nutritional counseling,
obesity reduction and increased physical activity

• Provide health education to members and family members about preventing and managing chronic
conditions using evidence-based sources

• Provide self- management support and development of self-management plans and/or relapse prevention
plans so that clients can attain personal health goals

• Promote self-direction and skill development in the area of independent administering of medication and
medication adherence

Comprehensive transitional care:

• Engage clients and/or caretaker as an alternative to the emergency room or hospital care

• Participate in the hospital discharge process

• Perform medication reconciliation

• Facilitate development of crisis plans

• Monitor for potential crisis escalation/need for intervention

• Complete follow-up phone calls and face to face visits with client/families after discharge from the emergency room or hospital

• Identify and link to long-term care and home and community-based services

Individual and Family support services:

• Assist clients in accessing needed self-help and peer/ family support services

• Advocate for member and families

• Provide family support services for members and their families

• Assist members to identify and develop social support networks

• Assist with medication and treatment management and adherence

• Identify community resources that will help members and their families reduce barriers to their highest level of health and success

• Link and providing support for community resources, insurance assistance, waiver services

• Connect to peer advocacy groups; family supports networks, wellness center, NAMI, and family programs.

• Support Medicaid adherence effort

Referral to Social and Community Services:

• Provide resources, referrals or coordination to the following as needed: Primary Care providers and specialist, Wellness programs, including tobacco cessation, fitness, nutrition or weight management programs, and exercise facilities or classes, Specialized support groups (i.e. cancer or diabetes support groups, NAMI psychoeducation), School supports, Substance use treatment links and treatment, support recovery with links to support groups, recovery coaches, and 12 step program, Housing services, Transportation services. Community programs that assists clients in their social integration and social skill building, Faith-based organizations, Employment and education programs or training; Volunteer opportunities.

Education: Bachelor’s degree required. Preferred in social work, psychology, human services, or related field.

Experience: One year experience working with adults with serious mental illness. Previous case management, care management, or care coordination experience.

License(s)/Certification(s): Possess a valid driver’s license.

Knowledge/Skills/Abilities: Coordination - Adjusting actions in relation to others' actions. Monitoring - Monitoring/Assessing performance of yourself, other individuals, or organizations to make improvements or take corrective action. Critical Thinking - Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches
to problems. Active Listening - Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times. Writing - Communicating effectively in writing as appropriate for the needs of the audience. Time Management - Managing one's own time and the time of others. Social Perceptiveness - Being aware of others' reactions and understanding why they react as
they do. Customer and Personal Service - Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction.

Other: Use of usual and customary equipment used to perform essential functions of the position.

Salary : $5,000