Care Coordinator

About the role

The Care Coordinator works as part of the Care Coordination team under the supervision of the Program Supervisor. The role involves addressing member needs, updating care plans, and conducting outreach.

Responsibilities

• Coordinates care for a caseload of 30-35 members
• Maintains monthly contact with all members of assigned caseload, with increased contact for newly enrolled and high-risk members
• Upon handoff from the Outreach Team, conducts member engagement activities, including face-to-face, mail, electronic, and telephone contact
• Establishes and maintains effective communication with primary and specialty care physicians, substance abuse and mental healthcare providers, family, collateral resources, and other agency staff on behalf of members
• Maintains documents, records, statistics, and other related reports in an organized, timely, and accurate manner as per policy and procedure
• Conducts initial and periodic needs assessments, including assessing barriers and assets, member and family/caregiver preferences and language, literacy, and cultural preferences
• Affords assistance in developing and executing members’ care plans, including helping members understand care plans and instructions and tailoring communications to appropriate health literacy levels
• Records client progress according to measurable goals described in his/her care plan
• Affords assistance in arranging for transportation and scheduling and accompanying members to appointments
• Affords assistance in identifying available community-based resources and actively managing appropriate referrals, access, engagement, follow-up, and coordination of services
• Affords assistance in assisting members with managing daily routines related to healthcare and incorporating members’ strengths and identifying barriers
• Affords assistance in conducting outreach and engagement activities that support continuity of care, including re-engaging members in care if they miss appointments and/or do not follow up on treatment
• Provides crisis intervention and follow-up
• Maintains monitoring of member entitlements, insurance, and other benefits to ensure they remain active and in place
• Advocates for members to resolve crises
• Collaborates with other professionals to evaluate members’ medical or behavioral health conditions and to assess members' needs
• Manages wrap-around funds, metro cards and checks for member purchases, including obtaining the necessary approvals for all purchases in keeping with the member’s goals

Qualifications

• High School Diploma/GED and two years of related human services experience in providing direct services to individuals with chronic health and/or behavioral health disorders