Care Coordinator

ESSENTIAL FUNCTIONS

• 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, conduct member engagement activities, including face-to-face, mail, electronic, and telephone contact
• Establish and maintain 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
• Maintain documents, records, statistics, and other related reports in an organized, timely, and accurate manner as per policy and procedure
• Conduct initial and periodic needs assessments, including assessing barriers and assets (i.e., transportation, community barriers, social supports); member and family/caregiver preferences and language, literacy, and cultural preferences
• Assist with the development and execution of members’ care plans, including helping members in understanding care plans and instructions and tailoring communications to appropriate health literacy levels
• Record client progress according to measurable goals described in his/her care plan
• Assist members with accessing healthcare and social systems, including arranging for transportation and scheduling and accompanying members to appointments
• Assist members with identifying available community-based resources and actively manage appropriate referrals, access, engagement, follow-up, and coordination of services
• Assist with coordinating members’ access to individual and family supports and resources
• Assist with 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
• Provide crisis intervention and follow-up
• Monitor member entitlements, insurance, and other benefits to ensure they remain active and in place
• Advocate for members to resolve crises
• Collaborate with other professionals to evaluate members’ medical or behavioral health conditions and to assess members' needs
• Manage 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

• Bachelors degree and two years of related human services experience in providing direct services to individuals with chronic health and/or behavioral health disorders