Care Coordinator - Enhanced Care Management

Description

Summary:

Under the direction of the Enhanced Care Management (ECM) Supervisor and working closely with the providers/staff at multiple NH health centers and the ECM Care Team team members, the Care Coordinator is responsible for the coordination of care for complex patients with mental illness, substance use disorders, or chronic conditions to navigate and link with community resources that address social determinants of health (SDOH). The Care Coordinator provides care coordination and connection to services and social supports for ECM Patients, including appointment scheduling and referral management.  This position will require travel to other NH sites to attend the designated meetings as well as training for staff members.

Requirements

DUTIES & RESPONSIBILITIES:

• Provides ongoing monitoring of the Targeted Engagement List (TEL);
• Assigns Patients to the appropriate ECM Care Team members based on risk category and available clinical data for ECM engagement activities;
• Responsible for primarily working with a caseload of Patients identified as being low risk (Tier 3);
• Conducts periodic telephonic outreach and follow-up to low-risk ECM Patients as outlined in the Shared Care Plan;
• Supports other ECM Care Team team members with delegated tasks;
• Assists in the coordination of appointments and referrals for physical and behavioral health appointments;
• Collaborates on Patient care issues with other ECM Care Team team members, participating in weekly systematic case reviews and ad hoc case reviews, and consults with ECM Care Team RN and/or the Behavioral Health Care Team RN before taking any action that is clinical in nature;
• Connects ECM Patients to other social services and supports he/she may need;
• Uses relationship-based strategies to engage Patients in care as well as motivational interviewing;
• Assists with arrangements such as transportation, directions, and completion of durable medical equipment requests; and
• Coordinates with ECM Patient in the most easily accessible setting, within IEHP guidelines (e.g. could be patient home, provider or regional office, or other settings).

QUALITY MANAGEMENT & RECORDKEEPING: 

• Contribute to the success of the organization by participating in quality improvement activities.
• Document as necessary in ECW for all care coordination and other services or teaching provided in a timely manner.
• Prioritizes activities according to intensity, need, and required follow-up.
• Provides accurate and timely reports to supervisor and site staff as required.

REQUIREMENTS:

• School Requirements: High School diploma/GED required
• A minimum of 2 years of work experience in a health-related field required 
• Familiarity and experience in the areas of community outreach, behavioral health, and working with high-risk populations. 
• Equivalent combination of education, training, and work experience to demonstrate the ability to perform the above tasks.
• Bilingual (English/Spanish) is highly preferred.
• May travel to other NH sites for training or meetings. CA driver’s license and proof of car insurance are required.

KNOWLEDGE AND ABILITY:

• Knowledge of medical terminology.,
• Computer skills including familiarity with spreadsheets, databases, scanning, printing, and faxing.
• Microsoft Office and Excel programs. 
• Strong communication and organizational skills. 
• The ability to interact effectively with clinic personnel, patients, and community-based organizations.
• Highly skilled interpersonally, with excellent teamwork and relationship skills. 
• Knowledgeable about evidenced-based communication such as Motivational Interviewing, or similar empathy-based communication strategies (emotional intelligence). 
• Highly skilled in interpersonal communication, including resolving conflict. 
• Able to sufficiently engage members and providers both on the phone and in person. 
• Understanding of and sensitivity to the multi-cultural community. 
• Understanding of and sensitivity to mental health conditions and addictive disorders. 
• Awareness of the impact of unmitigated bias and judgment on health; commitment to addressing both. 
• Strong organizational skills, typing 45 words per minute, proficiency in Windows applications, telephone courtesy, high degree of patience, and experience in data entry. 
•  Understanding of, and a commitment to, high performing team practices.