Care Coordinators link adults and children with chronic behavioral health and medical conditions to the services they need to stay as healthy as possible and inspire the people they serve (members) to use those services to optimize their health outcomes. Working in a team setting and primarily in the field, Care Coordinators assess risk and needs, develop person centered care plans, provide care management services, track and arrange appointments, educate members and coordinate other aspects of members’ health and community services. As this is an evolving program, additional responsibilities will be added.
KEY ESSENTIAL FUNCTIONS:
- Integration of medical, specialized and behavioral health services in addition to social support and/or educational support services
- Periodic assessment of a member’s medical and behavioral health needs as well as compliance with recommended treatments
- Collaborative development of an Individualized Care Plan (ICP) with the member, the member’s family and/or caregivers in addition to other service providers
- Providing required care management services
- Tracking all specialty medical, behavioral and support service referrals made for patient using Health Information Technology (HIT) provided.
- Assuring that member has access to, engages in and retains needed services as defined in the member’s ICP. Such services may include: Acute Medical Care; Primary Medical Care; Preventative medical care services (including metabolic screening); Home Health Care; Chemical Dependency Services; Behavioral Health Services; Community social support services; Housing; State and federal entitlements; Educational services; Involvement with child welfare, juvenile justice or criminal justice institutions.
- Providing outreach services to members for increased access to the above services
- Responding to members’ information and referral questions.
- Reassessing the need for ongoing care coordination services
- Completing all required documentation
- Sharing knowledge and experience with other team members to support the team’s overall service provision efforts
- Carrying an agency-provided cell phone
- Responding to member crises during (and occasionally outside of) regular business hours
- Other duties as assigned
ADDITIONAL FUNCTIONS MAY INCLUDE:
- Excellent written communication, verbal communication and customer service skills