POSITION OVERVIEW:
Care Coordination Redesign Care Coordinator under supervision of Program Director assist in supervising day-to-day operations of program, enrolls the client into the program and verifies eligibility. Performs the Intake Assessment including housing, food, medical provider, substance use, mental illness, case management services and other supplemental assessment. Conducts Reassessment with each client every six months during enrollment to coincide with service plan. Coordinates with formal/informal supports and develops the Comprehensive Care Plan. Oversees the implementation of the care plan with the support of the CCR staff. Provides Health Promotion activities as needed. Collects the Weekly program tracking and meets with the CCR team to review and coordinate scheduled services. Weekly case conferences with the CCR team will focus on 1-4 clients using the Case Conference Client Summary Forms (Appendix V). Conducts weekly reviews of Outreach efforts. Reviews include face-to-face assessment of staff competency and chart-based review for consistency and continuity of service documentation. Pays: $23.92 per hour
KEY ESSENTIAL FUNCTIONS:
- Responsible for client caseload, client enrollments (Intake)
- Coordinates and oversees the implementation of the Comprehensive plan.
- Performs the initial self-assessment upon client enrollment.
- Facilitates interdisciplinary conversation and planning with CCR team.
- Refers client for emergency shelter, transitional or permanent housing placement
- Supervised by PD in turn supervises CCR staff
- Schedules Outreach staff with client accompaniments, an Case Findings
- Provides coverage for CCR Program Director at Provider meetings.
- Will assists with direct service to the clients.
- Responsible for entering all data into the eSHARE System analyzing data and creating monthly reports. QA/QI for this contract.
- May conduct fieldwork including home visits and escorts to appointments and other identified services under CCR scope.
- Conduct outreach and engagement via phone, electronic methods, and letter and or field work to client/collateral/provider to engage clients or strengthen connectivity.
- Maintains compliant paperwork to justify service delivery
- Update weekly tracking services to be submitted for data entry.
- Gather enrollment consents, HIPPA/RHIO consents, and complete screening, baseline-risk assessments, reassessments, Care plan Development and Plan Update and notes in accordance with departmental policies.
- Accompany patient to Primary Care Provider appointments and document outcomes.
- Demonstrate the ability to clearly articulate, verbally and in writing, the aims and goals of the department to potential patients, community members and staff
- Access and respond per agency guidelines to client complaints of grievances
- Creating more effective linkages between vulnerable populations and health care system;
- Providing culturally appropriate health education on topics related to chronic disease prevention, physical activity and nutrition, and cultural competence;
- Promote hope and recovery by using strengths-based, culturally appropriate, and person-centered practices;
- Conduct CCR supportive and Health Education group activities
- Support Patient Navigator caseload
REQUIREMENTS:
- HS Diploma required
- BS in Social Work or related field preferred
- Bilingual (English and Spanish) preferred
- Six years case management experience with HS Diploma/GED
- Four years case management experience preferred (With AA/AS)