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Clinical

Health Home Clinical Care Coordinator

Buffalo

Summary of Position Function

The Care Coordinator will apply the essential activities of case management which include assessment, planning, coordination, monitoring and evaluation with the core components (Comprehensive Case Management, Care Coordination & Health Promotion, Comprehensive Transitional Care, Patient and Family Support and Referral to Community & Social/Support Services). The Care Coordinator will be responsible for the following outcomes: to reduce utilization associated with avoidable and preventable inpatient stays, to reduce utilization associated with avoidable emergency room visits, to improve outcomes for person with mental health illness and/or substance use disorders and to improve disease-related care for chronic conditions.

Education Requirements

  • Associate’s degree in health, human or education services and/or five years of qualifying experience* or LPN with experience.

Experience

  • “Qualifying Experience” means verifiable full or part-time experience in care coordination with the following populations: person with a chronic illness, and/or persons with a history of mental illness

Must possess a valid Driver’s License with an acceptable driving record.

Interested in this position?

Major Duties & Responsibilities

  • Complete a comprehensive health assessment/reassessment inclusive of medical/behavioral/rehabilitative and long term care and social service needs.
  • Complete/revise an individualized patient centered plan or care with the patient to identify patient’s needs/goals, and include family members and other social supports as appropriate.
  • Consult with multidisciplinary team on client’s care plan/needs/goals.
  • Conduct outreach and engagement activities to assess on-going emerging needs and to promote continuity of care and improved health outcomes.
  • Consult with primary care physician and/or any specialists involved in the treatment plan.
  • Prepare client crisis intervention plan.
  • Coordinate with service providers and health plans as appropriate to secure necessary care, share crisis intervention and emergency information.
  • Link/refer client to needed services to support care plan/treatment goals, including medical/behavioral health care; patient education, and self help/recovery, and self management.
  • Conduct case conferences with an interdisciplinary team to monitor and evaluate client status.
  • Advocate for services and assist with scheduling of needed services.
  • Coordinate with treating clinicians to assure that services are provided and to assure changes in treatment or medical conditions are addressed.
  • Monitor/support/accompany the client to scheduled medical appointments.
  • Follow up with hospitals/ER upon notification of a client’s admission and/or discharge to/from an ER, hospital/residential/rehabilitative setting.
  •  Facilitate discharge planning from an ER, hospital/residential/rehabilitative setting to ensure a safe transition/discharge that care needs are in place.
  • Notify/consult with treating clinicians, schedule follow up appointments, and assist with medication reconciliation.
  • Link client with community supports to ensure that needed services are provided.
  • Follow-up post discharge with client/family to ensure client care plan needs/goals are met.
  • Develop/review/revise the individual’s plan of care with the client/family
  • Consult with client/family/caretaker on advanced directives and educate on client rights and health issues, as needed
  • Meet with client and family, inviting any other providers to facilitate needed interpretation services.
  • Refer client/family to peer supports, support groups, social services, entitlement programs as needed.
  • Identify resources and link client with community supports as needed
  • Collaborate/coordinate with community base providers to support effective utilization of services based on client/family need.
  • Maintains complete, current and accurate member files which comply with The Health Home Standards.  Documents all member related activity in a progress note by the conclusion of the next business day.
  • Frequent or occasional driving of personal vehicle for purpose of transporting clients in the community and/or site visits (client or work related)
  • Other duties as requested.

SKILLS/COMPETENCIES:

  • Effective verbal and communication skills
  • Ability to teach and influence others
  • Demonstrated ability to work effectively in a team environment.
  • Demonstrated effective interpersonal relationship and customer services skills
  • Good organizational and time management skills
  • Ability to work effectively with people from diverse cultures and socioeconomic conditions.
  • Actively listens to others to understand their perspective and ensure understanding regardless of barriers.
  • Homelessness or chemical dependence. Experience with families preferred.
  • Critical thinking ability
  • Ability to handle protected health information (PHI) in a manner consistent with The Health Insurance Portability and Accountability Act of 1996.
  • Knowledge of computerized systems.
  • Knowledge of local and surrounding area resources

Interested in this position?

Other Clinical Positions Available